Comparing eight culturally similar European countries has confirmed the opinions of our national union of families and friends of people with mental illness and/or disabilities: incarceration is never a satisfactory solution, and is often the worst approach for an ill person. Treatment, no matter what kind, is always quantitatively and qualitatively insufficient, lacks follow-up, and is rarely given with reintegration in mind. Prisons, where there is widespread promiscuity, noise, pressure put on those receiving medication and heavy drug use, represent a factor that contributes to these troubles. Sometimes, incarceration can even be a trigger.

People with mental illness are overrepresented in European prisons and constitute about one-quarter to one-third of the prison population, while severe mental illness affects no more than 10% of the European population. This acknowledged and shocking overrepresentation calls for proactive responses from the prison sector.  

The lack of recognition and early treatment cause delays in diagnosis, leaving people to suffer on their own. This lag period is often accompanied by risky and addictive behaviours which can lead to “acting out”. 
In addition, prisons are overcrowded. With staff unable to make time to diagnose arrested individuals, people with mental health problems are increasingly being sent to prisons instead of hospitals. Moreover, in the case of France, there has been a brutal shift in psychiatric policies in the last thirty years, with the elimination of half of all psychiatric hospital beds. The director of the French prison administration recently confirmed this:”eliminating psychiatric beds has filled the prisons”¹.  

Finally, the way society looks at a “crazy person” is becoming increasingly less compassionate. Doctor Cyrille Canetti had this to say when leaving his prison psychiatry practice after 25 years: ”the way we look at a mentally ill patient has changed greatly in the last few years. People look more at the risk a patient may pose to society, forgetting that the patient is first and foremost someone who is suffering.”².  

 Prisons do not provide treatment, or provide it poorly; most mentally ill people should not be there. Yet, the harsh reality is that many of them are.

This harsh reality, which is increasingly being confirmed – as indicated by the spike in convictions after a brief drop due to COVID-19 – leads us to ask how it can be improved in France without legitimising the system. And if there is any way that the suffering of some 20,000 human beings unfairly affected by the system can be alleviated.

After reading the present document, one has a general impression that our neighbours, for the most part, have not come up with any better solutions than the French prison system. However, after a closer look, three approaches gained our (critical) attention and are briefly presented below:

In order to identify people who need care before a trial, some countries provide access to treatment as soon as an investigation is opened.  

In France, “summary trials”, intended to reduce court backlogs, makes almost half of people arrested appear before a judge within 36 hours. The investigators must then determine the social profile of an arrested person in a few minutes. This work is sometimes entrusted to contract workers from organisations with no psychiatric training, and they rarely identify mental health problems. Expert evaluations are unusual, since they are only necessary when serious crimes are committed.  

• In Germany, a judge may order “temporary placement” in a forensic psychiatric hospital. 
• In England and Wales, a temporary treatment order “remand to hospital for report” may be imposed during the trial phase.  
• In Italy, a judge may have the person placed temporarily in a specific psychiatric centre (REMS) during the trial phase, under an “interim security” order.  
• In Spain, a defendant may be placed in a forensic psychiatric hospital for a psychiatric assessment. 

In France, a judge can also order a psychiatric assessment for a defendant. In practice, the defendant usually has to wait ─sometimes for a long time─ in jail, where there is little to no treatment available.

Sometimes, prison guards are trained to better understand the behaviours of people with mental health issues and to “deal with them“.

In most countries, a large proportion of prisoners have mental health issues. Some prison administrations have seen the need to train their staff members to prepare them to deal with this role they may be forced to take on, particularly when healthcare workers are absent.  

Switzerland has the most impressive example of this: all prison guards receive five days of training in basic psychiatry. The training covers various mental health disorders and suicide prevention. Officers can also voluntarily participate in a 15-day training to learn how to deal with prisoners suffering from mental health issues and finish it off with a three-week placement in a psychiatric facility.  

Other countries have less consistent training:  

• In Belgium, prison guards must take six days of training in how to handle mental health issues. Those assigned to psychiatric wings must also have specific training.  
• In Germany, prison guards attend courses in psychology and criminology during their training, plus internships, and then on-going training sessions in psychology while they are working. In 2012, half of the 3,000-strong prison staff had been trained in mental health care. In Berlin, guards known as “group leaders” are trained in how to manage prisoners who present with mental health problems or risk of suicide. 
• In England and Wales, since 2016, new prison guards are obliged to attend mental health training sessions.  
• In the Netherlands, only the guards assigned to prison wings for prisoners with mental health problems (Extra Care Facilities, EZV) receive specific training. 

In April 2017, Dr. Guillaume Monod, psychiatrist at Villepinte prison, said: “[…] guards are regularly asked to take on the role of psychiatric nurses where, every day, they prevent suicide attempts, accompany prisoners to therapy, and restrain and isolate patients with acute mental illness“¹. In France, only one suicide prevention session is given to guards-in-training. Since 2019, a small number of prison guards, prison release and probation counsellors have voluntarily attended training and awareness sessions offered by Unafam.  

Continuity of care is sometimes (better) ensured after leaving prison. 

In France, continuity of care remains an unresolved issue due to the saturation of local psychiatry services (Medical-Mental Health Centres), their lack of appetite to provide treatment to a doubly stigmatised population and the absence of coordination between prison and civilian psychiatry services. This concern about the continuity of care exists in most of the other countries studied, resulting in institutional coordination mechanisms which are sometimes/often criticised because of the persistence, behind the scenes, of so-called “social defence” concerns: 

• In England and Wales, ”Clinical Commissioning Groups” (CCGs), in charge of local health services, are responsible for the care of released prisoners. In Wales, these patients can undergo a psychiatric re-assessment, the “Mental Health Measure”. They then have the right to get mental healthcare.  
• In Spain, prisoners in the so-called PAIEM program can access the Puente program which guarantees a “bridge” to getting treatment when released from prison. It is operated by the social reintegration centres, and a multidisciplinary professional team coordinates the continuity of care.  
• In the Netherlands, there is a “penitentiair programma” for those who have completed at least six months of their prison sentence. They are obliged to take part in several activities, including treatment.  
• In Italy, prisoners with serious mental health problems must be referred to public health agencies for follow-up when released from prison. 
• In Belgium, the TANDEM (Orientation et enregistrement après la détention et plus encore) service in the Flemish region ensures a reintegration plan for prisoners suffering from mental illness. “Treatment plans for incarcerated patients” projects (trajets de soins pour patients internés, TSI) were developed in Brussels and Wallonia to provide continuity of care. 

The implementation of such continuums in France is a cause for hope. Two “transitional mobile team” (Equipes Mobiles Transitionnelles) pilot projects are currently underway in Lille and Toulouse. They provide psychiatric and social follow-up for people released from prison, and establish contact between the prison psychiatric unit and the Medical-Mental Health Centre (Centre médico-psychologique). Unafam is involved in these initiatives and is hoping there will be more.

Institutional systems are always the result of a long history in which social, economic, political and cultural factors play an essential role. None of our European neighbours’ systems are transferable as such. The approaches discussed here are simply ways to improve the French system that has, for many decades now, been moving towards security-based psychiatry: one of the systematic criminalisation and penalisation of acts that go against social norms.  

In 1971, Michel Foucault analysed the expanding prison system by underscoring how the increased power of states put an end to the confusion between crime and war. Are we not seeing a return to this confusion? There is a slippery slope from “discipline and punish” to “discipline and predict”. 

In the end, the central issue in France today is the stigmatisation of people living with mental illnesses to whom a predictive justice is applied.