Prison Insider. What are your first thoughts at the association of prison and psychiatry?¶

Cyrille Canetti. It’s absurd and regressive.

Prison Insider. Is there a spike in the number of prisoners suffering from mental illness?¶

CC. Based on my observations, yes. I started working in prisons in 1996, so I’ve had the opportunity to reflect on this. I wouldn’t say the increase was linear. When I started out at Fresnes Prison, I was stricken by the condition of the patients I encountered. My feelings moderated over time. Within a brief span of time, I compared both my stints at La Santé: I witnessed a net increase in the number of patients with serious disorders. During the first stint (2009-2014), an average of 10-12 hospitalisations per year were registered. When the place reopened following its renovation, this figurehot up to 35-36 per year. However, this increase is a consequence of the prison’s service policy: I decided I would no longer deal with acutely ill patients. We systematically arranged for their hospitalisation. I became less conciliatory: I did not want the prison becoming a substitute for the hospital. My colleagues who still work there point out to me that the unit is overrun by psychotic patients. I feel that these people will increase in number as the cases increase in severity.

Prison Insider. What are the reasons behind this?¶

CC. There are several explanations for this. On the one hand, courts tend to imprison more and more mentally ill persons because they assume mental healthcare is available in prison, or simply because they don’t know what to do with such people. On the other hand, expert witnesses, when called to the bar, tend to make the accused look more accountable. Secondly, the victims increasingly expect some form of reparation from the trial. Finally, there is a shortage of psychiatrists over the years and are becoming less inclined to treat patients with a criminal record.

The new French Penal Code of 1994 instituted what is called “mitigated” responsibility whereas the former code provided either sufficient or abolition of discernment when the crime was committed. Consequently, several rulings due to alterations of discernment resulting to imprisonment. We further witnessed an increase in sanctions for persons with mental illness when their illness was not used to declare criminal irresponsibility. With the creation of UHSA (specially equipped hospital unit prisoners) in 2002, a senator went so far as to propose the abolition of Article 122-1 of the French Penal Code which enshrines the impossibility to convict a person deemed criminally irresponsible as there now exist facilities to accommodate the mentally ill. These are the reasons behind the increase in the number of mentally ill prisoners.

To tell you honestly, during the first 20 years of my 25-year career, I thought that healthcare should be increased, and for the next five years I thought that it should be reduced. The more we provide healthcare in prison, the more mentally ill people get sent there. The logic remains the same: the more prisons we build, the more people we imprison.

I also realised that being aware of these mechanisms did not solve much. It fell upon me to prevent someone from being incarcerated because the person simply did not need to be imprisoned. I telephoned the magistrate to express my concerns. She was sympathetic to my intervention. In the end, however, the accused received an even heavier sentence. I was stunned. According to the magistrate, her assessors conspired. They said: “There’s a prison psychiatrist here who takes things seriously. We can pass harsher sentences then.” This was the fruit of my intervention. The development of prison healthcare has only turned the prison into a sick house.

Furthermore, there is a shortage of psychiatrists. As a result, the needs of the population cannot be all met. Patients are driven to commit acts of delinquency that are only indirectly related to their illness. By closing beds, psychiatric facilities have turned people in precarious conditions out into the streets where they turn to crime to survive, and end up in prison. But in my opinion, the shortage of psychiatrists is not the only explanation to this phenomenon. Modern psychiatry has also changed its orientation and is now wrapped up in neurosciences rather than the social and environmental origins of mental illness. It is more focused on the workings of the brain and less focused on the workings of the individual.

PI. Does the trial play a role in this evolution?¶

CC. Two factors are responsible, I would say. First, the prevalence of summary hearings that resemble executions. All of it proceed at such a furious pace that there is no time for personality profiling. Sentences are passed without knowledge of the person. Courts do not realise that in so doing, they are sending seriously ill people to prison. If they do realise this, the accused are still helpless. Trials culminate in the dispatch of individuals to prison under the logic that healthcare is available there.

Second, the function of trials has changed. Formerly, justice served to underscore the authority of the state, and the judge served to reaffirm the law. The role of the victim has now magnified, and the focus of the trial errs on the side of the victim.

Now, trials are more about helping victims than judging defendants. The trial has become a place of care.

As if the extent of reparation were related to the weight of the sentence. The heavier the sentence, the more the victim will be able to heal or, like in the especially popular expression, work through their grief. Indeed, if we consider that a victim must identify a recognised perpetrator to achieve closure, it becomes impossible for perpetrators to be considered irresponsible. The Dati Act of 2008 enshrines this change. It was effected in the aftermath of the Dupuy Case, named after a young schizophrenic man who murdered two caregivers at the psychiatric hospital in Pau. The Dati Act makes it possible for the mentally ill to be brought before the examining chamber. The trial is intended to be therapeutic for the victims. The alleged crime goes down in the criminal record, guilt is definitively established, but the accused is declared criminally irresponsible. Healing the victim entails convicting the accused.

PI. How does prison affect the mentally ill?¶

CC. Prison is a catalyst. It escalates everything: the injustice that exists outside its walls, violence, problems. Each one of us toes the line between normality and insanity. Maintaining this equilibrium, albeit with minor daily variations, keeps us stable. All of us rely on artifice to bear our sorrows, our anxieties, our weaknesses. The more means we have to act on our environment, the more we are able to cope with these difficulties. If you experience insomnia, you can get out of bed, smoke a cigarette, take a stroll around the block, snack on something from the refrigerator, listen to the radio, or watch some television. If you experience the same insomnia in prison, you cannot get out of bed because you’re in a cell with two other people, and you can’t afford to step on your cellmate who is asleep on the floor. There’s no television or cigarettes, nowhere to go, no one to talk to, no window to open. You will experience insomnia in full force. So, it is with anxiety and depression.

Prison diminishes the capacity to act. The disciplinary ward intensifies this disempowerment because you are stripped of every means of coping mechanism. All your weaknesses exacerbate irrespective of your particular mental illness.

As for those who are depressed in prison, need I say more? If you’re in prison and not depressed, that’s suspicious. On the other extremity, there are those who suffer from manic episodes and need space to express their madness in their excited psychic state. They must be able to come and go, to run, to yell, to spend all their money. In a 9x9 cell, none of this is possible. The enclosure aggravates their issues and makes their suffering unbearable. Likewise, a person who suffers from hallucinations of persecution is permanently confronted by an inescapable delirium fed by compounded anxiety.

Prison is the home ground of every violence. You are victimised by yourself, your cellmates, the prison officials. You are a victim of confusion and misunderstanding. Of everything.

All stakeholders—doctors, lawyers, prison rehabilitation and probation counsellors (conseiller pénitentiaire d’insertion et de probation, CPIP)— can be cruel, if only by saying, “I don’t have the time to visit him today. I’ll go tomorrow. He’ll be there anyway.” Meanwhile, the person to whom they made a commitment waits expectantly. Prison is certainly not a place to alleviate illnesses.

PI. Are mentally ill prisoners more susceptible to suicide?¶

CC. The urge to commit suicide isn’t necessarily pathological. Suicide sometimes seems like the only route of escape from an unbearable situation. Certain environments push people to commit suicide, and prison is one of them. However, improving the material conditions of imprisonment is within anyone’s reach, and very little is needed to make things more bearable. Prison in itself is suicidogenic. It’s not that people there are sicker. People who hang themselves in their cells, who commit suicide in the disciplinary wards, who slash their throats after receiving bad news during visitation, who have no other means to respond, aren’t necessarily affected by mental illness.

Some administrative officials blame suicide on the fragile mental state of the prisoners. That’s fallacious. Every sane person, once in prison, is susceptible to suicidal thoughts. In light of this, we wonder what we are doing as psychiatrists in the fight against suicide. By doing all we can to prevent suicide, assuaging the sufferings of prisoners, and enabling them to accept the unbearable, aren’t we playing into the penitentiary game? Aren’t we exempting the powers that be from improving the conditions of imprisonment?

Needless to say, we must fight against suicide, but at the same time, I am convinced that our presence in prisons as psychiatrists is an endorsement. We must strictly minimise our presence and avoid sympathising with a system we resolutely condemn.

It is not very complicated to engage in some form of suicide prevention. I know it’s going to sound stupid, but we have to be kind and attentive to one another. I’ve often told my healthcare team that our kindness goes a long way. The involvement of certain teams means a lot when they treat people well, when they are soothing and respectful, when they absorb the feelings of injustice. But again, this is not the prerogative of caregivers.

PI. What are the main developments you witnessed?¶

CC. One of the biggest developments was regarding the approach of psychiatry. In Switzerland, near Geneva, there’s an establishment called Curabilis whose name alone sends chills up the spine. It is the essence of current evolution with its criminology-based approach. Psychiatry is intended as a tool to prevent recidivism, normalisation, and recovery. When I was head of department, the number of applications I received from psychologists who boasted of an interest in criminology and sexual offenders was unbelievable. It is really in vogue to consider healthcare as a means of redress. Part of psychiatry has put itself at the service of a society that is increasingly desperate for security. It is focused on making people compliant rather than providing them relief.

This is a view that traces its origins to the late 90s. In the 70s and 80s, we witnessed a desire to open up psychiatric services, to take care of all the people on French territory, including prisoners. The first health justice conventions occurred in this period. The 80s saw the creation of correctional psychiatry and the Regional Mental Health Department for Prisons (SMPR). The early 90s enshrined the independence of prison healthcare. Caregivers then, under the supervision of the Ministry of Justice, began to pass under the supervision of the Ministry of Health. But in 1998, the Toubon draft bill was passed. It provided for the legal monitoring of sexual offenders. In my opinion, this was the real watershed: the inflow of healthcare ordinances accompanying any legal follow-up. Then, gradually, the laws against recidivism came thick and fast. Secure detention centres were established in the aftermath of the Dati Act of 2008. Security became more rigorous, and care became an essential part of psychiatric expertise, an indispensable tool in the prevention of recidivism. What I have said encapsulates the convergence between psychiatry and justice.

I might have witnessed the golden years of prison healthcare until the early 2000s after which it took a nosedive. I don’t know if this change was real, or if I imagined it. But what is certain is that it’s not something new. Quite simply, maybe I can’t stand it anymore.

We no longer think of the mentally ill as people who are suffering. A schizophrenic is no longer seen as someone whose mind is in shreds, whose psyche is fractured. His suffering is considered abominable. He is primarily associated with dangerousness and a propensity to act upon it. Rather than a suffering individual, we see a threat to society. He is no longer someone who needs to be helped, but someone who has to be counteracted.

PI. The last two years were defined by a health crisis. Any realisations over that time?¶

CC. I was stunned by the extreme resignation of the prisoners. I assumed that with prisons overcrowding and the suspension of visits, we were going to witness an uprising. Instead, everyone was paralysed with shock. I noticed the same thing during scorching heatwaves. The heat surges to 40-45° in the cells. The despondency hits an all-time high as well. What unhinges me the most is this resignation culminating in acceptance. It surprised me how lightly it was taken.

Then, there were even fewer people in prison. Which means we were doing better work. I joked that the two things missing during the lockdown were honking horns and incarcerations. Parisians couldn’t stand not being able to honk anymore while the courts couldn’t stand not being able to incarcerate anymore. Of course, these have spiked again. I must underline that the prison administration has done well to implement telephone credits and video calls. There are, however, certain inconsistencies and abuses of power. For example, during the lockdown, every citizen had the right to one-hour walk outside within a one-kilometre radius. This was not possible for people at the day parole centre who had no way of getting out. If they wanted to take a walk around the outside of the prison health centre, it was not possible. My fellow doctors denied them this privilege as they considered them less able to comply with health precautions. Such infantilisation is often reflexive in the medical community. These prohibitions are passed without consultation in the name of the greater good. Also, in the name of greater good, doctors have intensified the deprivation of liberty and transgressed the law.

Unfortunately, healthcare professionals are often influenced by the duties of the prison system, and the duties of surveillance and protection. For example, in cities, doctors are aware that patients can take their medication incorrectly, not take it at all, or disregard the dosage. In prison, they are extra careful about adhering to prescriptions, and ensuring that the drugs are not tampered with, as if patients in prison ought to be more dutiful than their counterparts in the outside world, as if prison healthcare workers ought to participate in policing.

PI. Speaking of prison management, what are your views on the role of the Contrôleur general des lieux de privation de liberté, an office that you yourself held?¶

CC. Being able to enter all places of deprivation of liberty is undoubtedly a step forward. Having the right to scrutinise is quite exceptional. The office of the Comptroller General is relatively new and has much to offer. It’s a pity that its actions are not more binding and limited to recommendations that are not necessarily heeded. The prison system is improved and shaken up thanks to this office. The prison administration has become considerably transparent, an unusual feat. Gradually, this office will solidly attack the foundations of the system.

Personally, I find that we are too caught up in the administrative side of things. That’s probably because our teams aren’t populated by zadists ¹ [laughs]. And we sometimes lack courage, in my opinion. We once visited Château-Thierry Prison which intends to take in persons with behavioural issues, adjustment disorders, and others who cannot be treated within known pathological parameters. According to the circular, the personnel at Château-Thierry are not accountable to the UHSA and are not under the aegis of the SMPR. The status claimed by this establishment is a lie. The prisoners say the psychiatrists decide on their release, and forestall transfers if they have not taken their treatment. This is the worst psychiatric care imaginable.

The report on Château-Thierry did not make much of a noise. It did not achieve the desired impact. I was very disappointed. It was truly a scandal.

Christiane Taubira, erstwhile Minister of Justice, remarked about this establishment: “We don’t have the means to renovate it, nor can we do without it.” Château-Thierry is an utter liability that ought to be shut down.

Coming to the duties of the office, its mission is extremely complex. It boils down to the defence of fundamental rights, a very broad domain. Sometimes I wonder about their sense of priority, about the scrupulous examination of the response time of mail and its routing. Of course, that’s all important, but it lacks that personal touch. Maybe the Comptroller General ought to get more involved? I don’t know. However, the fact remains that this office is very important. It is necessary to emphasise its weight so that its opinions are not treated as just another report that will end up at the bottom of a drawer.

PI. Let’s talk about politics. During the 25 years of your career, you have witnessed four presidents over five terms. What can politics do? Does a solution lie there?¶

CC. Politicians are completely impotent in these matters, and don’t give a second thought about them. I’m probably utopian, and it’s certainly not that I lack courage. Nobody cares about the affairs of prison, including the psychiatric hospitals that are willing to take care of madmen, the genuine kind. This indifference undoubtedly contributed to my ousting. The purpose of reintegration is a grand hypocrisy because prison operates under the logic of security that demands the protection of citizens. If prisons continue to function as such, people will relapse and end up worse than they originally were. Prison, such as it is designed, releases people who become even more damaged, poorer, sicker. A promising political motto would be: “If you care about your security, change your system.”

We claim to act for security, but do the opposite. Counterproductive though it is, this discourse has remained fundamentally the same for decades with anecdotal variations.

Let’s take the example of medical confidentiality. Courts and policy demand exceptions to this confidentiality when the defendant presents a danger, especially in the case of sexual offenders and paedophiles. Just take a look at bills that push for the disclosure of medical information. Proposals provide for a psychiatrist to notify the prosecutor or sentencing judge when he perceives the possible risk of recidivism in a paedophile. On a human level, the idea is clearly understandable: we aren’t going to expose our pretty selves to sexual predators. But if you consider that a psychiatrist’s working tool is trust and that paedophilia isn’t a disease, that’s not possible. Paedophilia cannot be treated with antidepressants and anxiolytics, but through psychotherapy which requires trust. If trusting a psychotherapist can affect criminal proceedings, patients will no longer confide in us. Care will no longer be provided, and the opportunity to help them to not repeat the acts that led to their imprisonment is lost.

Policy-makers are incapable of insisting on the inviolability of medical confidentiality as it is our most important tool for healthcare.

In short, policy developments are detrimental to common sense. They go with the times. The little allowances we have are misused.