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France: everyday madness

Two days with a psychiatrist from Baumettes prison

What can prisons do for people with mental health problems? Since 1986, the Regional Mental Health Department for Prisons (SMPR) have been able to provide day hospitalisation for prisoners who require special attention. The SMPRs, present in 26 French penal facilities, meet multiple needs, such as: screening for mental disorders, medical and psychological care, and preventative care.

Eric Kania has been a psychiatrist at Baumettes prison in Marseille for over 20 years. He wrote to Prison Insider after the publication of Walling up madness to provide further details and give his point of view. Prison Insider interviewed him.

He told us about his day-to-day at the Baumettes SMPR.

I usually arrive at the SMPR at 8 a.m. and finish at 6:30 p.m. The days are fairly predictable, although of course there are some exceptions. Normally, we have a team of eight psychiatrists; six are full-time and two are part-time hospital practitioners. I work 40% of the time myself. For years now, there have been about four vacancies. At the moment, we are in quite an unusual situation: out of our team of eight psychiatrists, one is on maternity leave, one has COVID, and two are on vacation. Only four of us were working last Thursday, and then just two of us on Friday. It was non-stop!

Afterwards, I attended a so-called “Day 30 feedback meeting,” which lasted about two hours. That was the first time I had ever been to one of these meetings. It was very impressive.

Thursday

Feeling attached. The day started with a short consultation with a patient that I have been seeing since he was 18 years old. He is now in his thirties.
Since childhood, he has been receiving treatment for cognitive disorders. During his first stay in prison, he struggled to adapt to the prison environment, much so that he was placed in a disciplinary ward. This placement had disastrous consequences; he set himself on fire in his cell.
He was in intensive care for some time before we admitted him to the SMPR for several months. He got back to prison only recently; there isn’t much for him on the outside. He is attached to our team. It is a bit like his home here. His condition has improved over the last few years: he is receiving less severe psychiatric treatment than 10 or 15 years ago. He has adjusted quite well to the prison environment, and has no behavioural problems. I do not know if this is reassuring or not, but that has been his progression.

30 days. Afterwards, I attended a so-called “Day 30 feedback meeting”, which lasted about two hours. That was the first time I had ever been to one of these meetings. It was very impressive. The three guards present at a suicide incident, when they were still trainees, told us about their intervention during the said event they experienced, such as: untying the robe around the person’s neck, waiting for the arrival of the fire brigade and the police, the prosecutor and the medical examiner. I was moved by the story of these young people who did what they could but unfortunately were too late. I personally did not know the person who committed suicide. I know that she had met an intern in psychiatry and a nurse from the SMPR. Everyone agreed that there were no warning signs or any obvious psychological problems. Committing suicide seemed somewhat incomprehensible to us.

This type of meeting is part of a procedure implemented by the prison administration. The first meeting is organised within 24 to 48 hours of the incident, with the team of guards who intervened. A second “feedback” meeting is held one month later. The meeting is attended by the guards present at the time of the incident, the head of the establishment, the “suicide officer”, a psychologist from the Interregional Directorate for Prison Services, a probation officer, a medical inspector from the Regional Health Agency, and a psychiatrist from the SMPR, among others.

Making the connection. After, I go back to my department to answer some emails and calls, and then it’s time for lunch. Every Thursday at 2 p.m., I have a meeting with the team of somatic doctors and nurses who work at the women’s prison. The aim is to discuss complex clinical situations, particularly, those of women who have just arrived in detention or who have somatic and psychiatric disorders. At the moment, we are dealing with a case of an incarcerated patient suffering from a severe neurological disease called Huntington’s chorea. It causes many disorders, including balance impairment. It is a difficult condition to manage in prison. We asked for a suspended sentence, but it is very complicated: the patient lost her home and was imprisoned due to behavioural problems linked to her illness. For all these reasons, finding her a place to stay is a real challenge. Next, I see four patients in my office, mostly women. The day ends as it began: with consultations

In the 26 facilities which conduct SMPR, the day hospital operates at a level 2 care. The nursing staff is only present from 8 a.m. to 6 p.m.

Discover: "France: everyday madness"

Friday

The day hospital. On Friday, there were only two of us. I was on call for new arrivals and emergencies. As my colleague was not present,
I also had to deal with emergencies at the day hospital, which I usually do not do. I met with three new arrivals who were referred by the doctor of the Prison Medical Consultation and Outpatient Treatment Unit (UCSA). A medical examination is mandatory upon entering detention. At the end of this first examination, we usually check if the person has any mental disorders, whether they are undergoing psychiatric treatment, or whether they have any reported history or requests for professional treatment.
I saw a man in his fifties. He arrived in a visibly diminished physical state. He had been on a methadone-based treatment for years. The consultation was fairly quick, as his psychiatric condition seemed stable. He did not wish to dwell on the reasons of his incarceration. He had been in custody for several days. He was tired. Mainly, he wanted to be able to resume his treatment, which was not a problem for me.

Emergency. Then came the emergencies, including a patient I have known for years. This case kept me busy from 9am until the end of the day. He is 25 years old and suffers from dysthymic schizophrenia. He has been under psychiatric care since he was 18 years old. He has been in prison for three or four years. Our team has transferred him to the psychiatric hospital several times.
He was discharged from hospital last week. As soon as he returned, he informed us that he was no longer ill and that he had stopped taking his treatment. So, we called him every day, but we could not get him to change his mind. Unsurprisingly, he relapsed on his treatment: yesterday night, he wrecked everything in his cell. The regional intervention and security teams (ERIS) had to intervene, and they calmed him down by giving him cigarettes. He was clearly delirious, so he was sent back to our department. I let him go back into detention and explained that I was going to send him back to the hospital. This usually takes time because the process is a bit complicated. Of course, there were no places at the hospital, so we had to find one for him elsewhere. To do this, the prefect’s delegate must sign a prefectural decree and the ambulance transfer must be organised. When I left at 6 p.m., the patient had not left yet. If everything goes well, the ambulance will pick him up in the evening and take him to a hospital for the time being. This is pending his transfer, early next week, to the hospital where he is usually treated. He should then be taken care of at a Specially Equipped Hospitalisation unit (UHSA) within 15 days.

I was very worried about the whole situation. I even dreamt about it last night. The subconscious mind keeps on thinking, even once the day is over.

I also saw a patient from the day hospital whom I did not know. He was evidently psychotic with delusions of persecution, and he had set his cell on fire the night before. The guards had to take emergency action, put out the fire, and move the patient. He had already been hospitalised several times in psychiatry, and we were at a loss. We ultimately decided not to do anything for the time being, and to instead discuss the case with the doctor from the day hospital on Monday. Together, we will decide whether the patient needs a transfer to the hospital or whether he should be kept in detention. This situation is not ideal and in fact, it is quite precarious. The situations we face are often complex: we hesitate, we are conflicted, and we want to avoid forced treatment. But it is not always possible to get the person’s consent. Sometimes, the only option is looking for “agreement”.

Absenteeism. I continued with consultations in the afternoon for patients that are on an outpatient basis. Eight consultations were scheduled but only four people showed up. It is not surprising, since there is generally a high absenteeism rate. It was a blessing in disguise though: it allowed me to support the patient I was caring for that morning, and to manage other emergencies.

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