France has 187 prisons. Since 1994, prison health care falls under the authority of the Ministry of Health. Prison mental healthcare was the subject of a major reform in 2002.

People declared not criminally responsible are subjected to treatment orders in psychiatric facilities. The court can decide to place them in a Unit for Difficult Psychiatric Patients (Unité pour malades difficiles, UMD). In 2019, 58 people were declared not criminally responsible due to mental health problems following a preliminary inquiry. This represents 0.0017% of the 33,118 cases sent back to trial. Prisoners deemed criminally responsible who suffer from mental disorders are usually placed in ordinary prison regime.

The mental healthcare management in prison is organised by level. Level 1 psychiatric care is provided through outpatient consultations in Prison Health Units (Unités sanitaires en milieu pénitentiaire, USMP) by general practitioners. Psychiatric care is delivered in level 2 units; these are the Regional Mental Health Departments for Prisons (Service médico-psychologique régional, SMPR) which are available in 26 prisons. They provide day hospitalisation. Prisoners who require full admission can be temporarily placed in units outside the prisons where level 3 care is provided.

Healthcare facilities with psychiatric departments have Psychiatric Intensive Treatment Units (Unités de soins intensifs psychiatriques, USIP), Units for Difficult Psychiatric Patients (Unités pour malades difficiles, UMD) and/or Specially Equipped Hospitalisation Units (Unités hospitalières spécialement aménagées, UHSA) available for certain prisoners. A prisoner is only placed in one of these external units at the request of a judge or a prefect (préfet, a senior civil servant responsible for their region’s administration). In the case of a USHA or UMD, the consent of the receiving institution’s board of medical directors is required.

The placement generally lasts only a few months, and patients are then transferred back to prison. In 2012, The European Court of Human Rights condemned France for inhuman and degrading treatment, with prisoners sent back and forth between psychiatric hospitals or units and prison, which “clearly impeded the stabilisation” of the prisoners’ mental state.

Since 2012, the Château–Thierry prison has accommodated prisoners suffering from severe mental disorders who do not require full hospitalisation. Transfer to this facility is at the discretion of the prison administration and it has around 100 places. The Controller-General for Places of Deprivation of Liberty (Contrôleur général des lieux de privation de liberté, CGLPL) is the French National Preventive Mechanism. In 2017 it reported the deplorable living conditions and the lack of care for the prisoners at this facility.

Prisons are overpopulated. During one of its visits, the CGLPL noted that this has led to punishing living conditions (overcrowding, tensions, violence, difficulty accessing showers), a decline in prisoners’ mental health, and it has made access to various forms of care more difficult (mental health treatments, shortening of the observation period in the new arrivals wing, abandonment of medical extractions). These conditions only serve to worsen prisoners’ mental health problems.

The latest national epidemiological study revealed that 35% of prisoners suffered from particularly severe mental disorders. Eight out of ten men in prison and more than seven out of ten women have at least one mental illness. A study carried out in Hauts-de France prisons in 2011 found that the proportion of prisoners with severe mental health disorders had risen to 22%, 7% of which suffered from schizophrenia.

People with mental health disorders are rarely identified during their imprisonment and are most often placed in ordinary prison regime. Access to activities differs from one facility to another. The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) reported that prisoners with a deteriorated mental state are placed in solitary confinement for long periods. The report deemed this practice unacceptable and “potentially dangerous.”

Access to mental healthcare  ¶

A nurse provides a medical evaluation for each person within 24 hours upon admission. If the nurse establishes the presence of a mental disorder, they inform the prison psychiatrist. Facilities equipped with a SMPR provide a psychiatric assessment for all new prisoners. However, the managers of the SMPR at Paris-la Santé prison choose not to provide this evaluation. They consider it to be too intrusive. As an alternative, they offer an introductory session during which prisoners can request a psychiatric assessment.

Waiting times for consultations are usually long. The CGLPL reported that in 2016, prisoners at Fresnes prison waited one or two months before being able to see a psychologist. Prisoners at Béziers prison could wait up to eight weeks before being admitted to the SMPR in Perpignan.

Provision of mental health treatment¶

Each prison must offer access to outpatient psychiatric care, including psychiatric and psychological consultations. Level 1 care is delivered by the health units and the SMPRS in the institutions concerned. Only the SMPRS provide level 2 care.
The treatments provided vary between each SMPR. The SMPR at Paris-la Santé prison provides occupational therapy sessions. Bordeaux-Gradignan prison offers many treatments and various activity sessions.
The CGLPL found that the SMPR in Fleury Mérogis prison offered very few treatment activities. This was attributed to a lack of human resources.

Château-Thierry prison mainly provides medication treatment. The CGLPL reported that many people claimed to have received treatment against their will, out of fear of being forcibly injected. The CGLPL considers these practices to constitute inhuman and degrading treatment.

Medical staff¶

Twenty-six SMPRs in France provide day admission for prisoners who require special attention. Prisoners must consent to this transfer. Some SMPRs also have cells for keeping patients overnight. However, there are no medical staff present during the night. The SMPR in Réunion, for example, has six cells for around 1,000 prisoners. The prisoners hospitalised there are rapidly reintegrated back into ordinary prison regime.

The quality of care depends on the coordination between the physical and psychiatric treatment. The CGLPL reported that the different medical teams in the Baumettes SMPR held regular meetings together. The psychiatry team is made up of psychiatric doctors, psychologists and also occupational therapists and social workers.
Other facilities take similar steps to ensure this kind of coordination. In Condé-sur Sarthe prison, a department meeting is held every week with the physician, nurses, psychiatrist and psychiatric nurses. The CGLPL report specifically mentioned that “A medical software (Cora) is used to manage each individual’s medical file. It allows psychiatrists and physicians to see one another’s prescriptions and observations.” This level of coordination is not systematic, the CGLPL pointed, for example, to the unfortunate absence of coordination in La Santé prison.

Some SMPRs are lacking staff, such is the case at Fleury-Mérogis. The health unit changed building in 2015 and lost four day hospitalisation places as a result. The CGLPL pointed out that the means and conditions of care were “largely underestimated” considering the size of the prison. In 2018 the prison held almost 4,000 prisoners. The report highlighted that there are few consultation offices and an insufficient on-call system. The CGLPL described how “the presence of psychiatrists in the care units (…) fluctuates, which does corroborate the data on appointments (…) There is no on-call system for nights, week-ends or bank holidays.”

Medical confidentiality ¶

Medical consultation requests are made in writing, posted in dedicated letter boxes. The prisoner can also make a verbal request for a medical appointment to a prison guard or medical staff. Nurses are responsible for the distribution of medication. In order to respect patient confidentiality, prison staff must be absent from medical consultations. However, in practice, the layout of the facilities and the permanent presence of guards do not always guarantee compliance with medical confidentiality.

Emergency measures ¶

Prisoners in a state of mental health crisis are usually firstly placed in a disciplinary confinement cell or an emergency protection cell (cellule d’isolement disciplinaire ou de protection d’urgence, CproU). CproUs are generally reserved for prisoners who present a suicide risk. In theory, the duration of placement in these cells cannot exceed 24 hours. In reality, a prisoner who arrives on Friday evening can spend the weekend there.

Prisoners in a state of mental health crisis can be transferred to a general psychiatric hospital. Such transfers occur when treatment inside the prison is not possible (if there is no SMPR inside or near to the prison). Moreover, the majority of SMPRs do not provide treatment overnight or on weekends. This frequently leads to overcrowding in the accident and emergency departments in general hospitals. The CGLPL noted, for instance, that the large proportion of admissions into Cochin hospital take place in the evenings and the evening before the weekend. It explained “Accident and emergency departments criticise these practices. They believe that the patients could have been referred to other services or that the SMPR could have pre-empted certain clinical situations of psychiatric decompensation with treatment.”

Treatment without consent is only permitted if the prisoner poses a serious danger to themself or to others. The CGLPL reported that involuntary treatment is common at Château-Thierry prison. Injections are forcibly given to non-compliant patients.

Prison officer training¶

Prison officers do not receive specific training on how to deal with people with mental disorders. The National School of Prison Administration (École nationale d’administration pénitentiaire, ENAP) offers some training. Unafam also offers training in mental health first aid (premiers secours en santé mentale, PSSM) and training in mental disorder awareness.

It was concluded that the lack of training given to prison guards combined with the absence of opportunities for discussions with the medical staff have detrimental consequences for mentally ill prisoners. The CGPL reported that in Fleury-Mérogis prison “the lack of any time or place dedicated to dialogue between the prison and medical staff gives the impression, rightly or wrongly, that the information provided [by prison guards on prisoners in need of extraction] is not followed up.”

Château-Thierry prison accommodates severely mentally ill prisoners. Prison staff at this facility undergo training “to support difficult individuals”, mainly focusing on the care of prisoners who suffer from mental disorders. Training is supplemented by a work placement on a secure unit at Prémontré’s regional mental health facility.

Continuity of treatment¶

The Penitentiary Integration and Probation Service (Service pénitentiaire d’insertion et de probation, SPIP) is responsible for preparing prisoners for their release. They contact the prison medical staff to ensure continuity of treatment and may communicate with the family to include them in the process. Some prisoners see their health decline considerably in prison. It is rare for a sentence to be suspended for medical reasons, even though the law does allow for this when a prisoner’s health is incompatible with their conditions of detention. The CGLPL explained how “a prisoner’s release often brings an end to their social and medical care, this increases the likelihood of serious symptoms of mental illnesses returning.”

In Lille and Toulouse, two “mobile transitional teams” (équipes mobiles transitionnelles, EMOT) implemented mechanisms to aid a prisoner’s transition from incarceration back into the outside world. It offers support to individuals with mental illness who have been released from prison to facilitate their social reintegration. Care relays are also provided for released prisoners who need them, as in Marseille.

Involuntary admission¶

When a prisoner is declared not criminally responsible, the prefect may place them in a general psychiatric hospital.

Transfers from prison  ¶

Prisoners in psychological crisis are usually transferred to a general psychiatric hospital. They are not required to give consent. On the prison doctor’s advice, the prefect makes the decision to admit the patient into “care at the request of the representative of the State” (soins à la demande du représentant de l’État, SDRE). Hospitals can request that prisoner-patients be transferred to a UHSA.

Legal framework¶

Prisoners hospitalised in psychiatry have the same rights as the other patients. The Liberty and Custody Judge (juge des libertés et de la détention, JLD) monitors the measure 12 days after implementation, and then every six months. Prisoners can also submit a request to the judge at any time.

The psychiatrist suggests the patient’s return to prison to the prefect. The prefect is not obliged to follow the psychiatrist’s advice. In this case, the director of the psychiatric hospital must be informed. A second psychiatric examination is then required. When both psychiatrists agree, the JLD is automatically consulted.
Usually, prisoners are quickly transferred back to prison.

Daily life¶

The use of isolation and restraint on patient-prisoners is very common. Following a visit to the Bourg-en-Bresse psychotherapeutic centre in 2016, the CGPL reported serious violations of fundamental rights. Prisoners are systematically restrained until their first psychiatric evaluation, as well as during medical examination. The CGPL published urgent recommendations warning about these serious failings. A second visit in 2019 allowed to measure how practices had improved in the facility. The inspectors praised the “work they had collectively accomplished” and highlighted ”the profound change in patient care (…): the framework which made security measures the top priority in treatment has been replaced by one structured around respect for patients’ dignity, their rights and their liberty.”

In 2019, the CGLPL nonetheless observed the almost systematic use of patient-prisoner isolation in several facilities throughout the duration of their stay ”when their clinical condition does not justify it.”

Continuity of treatment¶

Prisoners are transferred back to prison when their condition stabilises. Communication of medical information between the hospital and the prison health unit is often difficult. Once they have served their time, release is usually abrupt, meaning no care is put in place by an outpatient psychiatric care facility. .

The prefect proposes the prisoner’s transfer to a specific facility and that proposal is sent to the relevant medical team for their approval. This usually happens when the prison can no longer provide the care a prisoner needs. Prisoners can be placed in a Specially Equipped Hospitalisation Unit (Unité hospitalière spécialement aménagée, UHSA), in a Unit for Difficult Psychiatric Patients (Unité pour malades difficiles, UMD) or in a Psychiatric Intensive Treatment Unit (Unité de soins intensifs psychiatriques, USIP). Prisoners can request a transfer to a UHSA.

Transfer. There are typically long waiting times for all facilities. Emergencies are therefore mostly handled by the general departments in psychiatric hospitals. Building the UHSAs has not been a sufficient response to the issue of mental health emergencies. Prisoners wait on average six months before being admitted to a UMD. In 2018, 7% of prisoner-patients were admitted to UMDs.

Placement duration. These facilities do not provide long-term care. Prisoners are usually transferred back to prison after a few months. Placements last between one and three months in UHSAs, six months in UMDs, and two or three months in USIPs. In reality, over 38% of these facilities do not set a limited period of placement.

Measure review. Patient-prisoners have the same rights of appeal as other patients. They can consult the JLD at any time to contest the validity of the admission without consent measure to which they are subjected to. The judge is also responsible for monitoring the need for isolation and restraint measures.
The Medical Monitoring Commission (Commission de suivi médical, CSM) of each UMD decides whether a person needs to be kept in a UMD. They must reassess the patient-prisoner’s mental state at most every six months. In particular, they check the standards of care by visiting the UMD they are responsible for at least once every six months. They then send a report to the Departmental Committee for Psychiatric Treatment (Commission départementale des soins psychiatriques, CDSP) and to the prefect.

Specially Equipped Hospitalisation Units (UHSA)¶

The UHSAs are hospital facilities established inside healthcare institutions. They are jointly operated by the Health Ministry and the Justice Ministry. The prison administration provides the staff responsible for external security.
These units accommodate, at the request of the prison doctor, prisoners for full hospitalisation with or without their consent. There are nine units with a total of 440 places. In 2018, The Health Ministry announced the construction of eight new UHSAs which would add a further 265 places.
The USHAs were intended as a solution to the emergency situations taking place in prisons. Yet the units have not risen to the challenge. The CGLPL found that the Marseille USHA “does not accept emergency patients, and its average admission times in 2019 were too long to provide care at the opportune moment. In the absence of a place in a USHA, the majority of psychiatric emergencies in prison result in hospitalisation in a psychiatric ward”. The average waiting time to be admitted into a USHA varies between regions. In the Department of Nord, the average waiting time in 2019 was nine days. The average waiting time in 2019 for the USHA in Condé sur Sarthe was between 35 and 39 days. The CGLPL described how: “As a result, patients in a state of mental health crisis have been inappropriately left for more than a month in their cell without any psychiatric follow-up”.

Daily life¶

The prison administration manages admissions and discharges for the USHA. It is responsible for the visits and searches. Living conditions vary from one UHSA to another. In some, patients can circulate freely during the day, as is the case in Marseille and Toulouse. In others, living conditions are similar to those on a hospital ward. Patients live in rooms and only medical staff are present within the premises. The rooms in the USHA in Vinatier were considered bright and spacious. There are individual bathrooms and the patients can decorate the walls. Smoking is not permitted and prison guards can be called by medical staff in the case of an emergency.

Treatment plans¶

Psychiatrists prescribe therapies and drug treatments. There are few activities outside of treatment time, which usually results in patient-prisoners becoming inactive. The care provided “does not seem to be able to meet the challenges of caring for people who have medical and social vulnerabilities, or aim to leave the prison system”.¹ The care team available differs from one facility to another. On average, there are two to five full-time psychiatrists. In 2017, only one facility has a full-time general practitioner. Nurses and psychologists are also present. Some facilities have psychomotor therapists, sports educators, occupational therapists, and physiotherapists. A social worker provides “educational, legal and social care”.

Training¶

Healthcare staff training. Healthcare staff are specifically trained in psychiatric care. Some are trained in elements of prison law.

Prison officer training. UHSA guards do not have specific training in providing care for people suffering from mental disorders.

Continuity of treatment¶

The care coordination plan for prisoners when they leave the UHSA to return to prison, has been deemed “unsatisfactory”². The medical teams on the unit rarely provide clear or precise information about the person’s care requirements needs. The SPIP is absent from the UHSA.

Units for Difficult Psychiatric Patients (UMD)¶

These units, set up in 10 psychiatric hospitals, receive patients who pose a danger to themselves or others. Due to the state of their health, following a medical proposal with a treatment goal, intensive care protocols, and individual security measures have to be implemented.
People declared not criminally responsible can also be placed there. Admission, which takes the form of full hospitalisation, happens without the patient’s consent. The UMDs currently have around 530 places. They are stretched beyond their capacity, as requests for admissions increase while the number of discharges is low.

Daily life¶

Living conditions in UMDs are similar to those in general psychiatric hospitals. No prison or surveillance staff are present, but there is a particularly strengthened medical team. The majority of patients spend between 18 and 23 hours a day in their room. The CPT observed that the patients at Cadillac UMD typically remain sat in armchairs in the communal areas, without any interaction from the care teams.

Treatment plans¶

Each patient receives a personalised treatment plan, which includes medical treatments and psychotherapy. The CPT reported excessive prescription of psychotropic medication to some patients. However, it highlighted the implementation of therapeutic education programmes for patients suffering from schizophrenia. The aim is to help them recognise risky situations and the warning signs of a crisis. The medical team is multidisciplinary; at least four psychiatrists, two general practitioners and two interns are always present. They are helped by approximately 40 nurses and care assistants.

Training¶

Healthcare staff training. Healthcare staff are usually trained in psychiatric care. Some are trained in prison law.

Prison officer training. UMDs do not have prison staff responsible for surveillance.

Psychiatric Intensive Treatment Units (USIP)¶

USIPs are closed high-security units in a medical facility. They can accept prisoners with severe behavioural problems who cannot receive proper care in a general psychiatric department.
These units in psychiatric hospitals accept patients, sometimes in emergencies, who pose a danger to themselves or others. Due to the state of their health, following a medical proposal with a treatment goal, intensive care protocols, and individual security measures have to be implemented.

Daily life¶

USIPs are secured wards with around 15 beds per unit. The CPT noted efforts to furnish the units but highlighted the austere nature of some of them.

In all facilities, isolation and restraint measures must be authorised by the psychiatrist. These measures should be used as a last resort, in case of serious danger to the health of the patient or others.

Treatment plans¶

The provision of treatment varies depending on the USIP. Activities such as occupational or psychomotor therapy are rare. The medical team is multidisciplinary, and there is a heightened presence of caregivers: on average, one nurse is present for every four patients. In 2019 the CPT revealed that so-called “as needed” prescriptions (Editor’s note: conditional, Pro Re Nata or “PRN”, medication prescriptions which can be added onto continuous prescriptions) for powerful sedatives were used for 90% of the patients in the Cadillac USIP. The CPT viewed this practice as “excessive”.

Training¶

Healthcare staff training. Healthcare staff are specifically trained in psychiatric care. Some are trained in prison law.

Prison officer training USIPs do not have prison staff responsible for surveillance.