The eight countries examined all have a system of care for offenders suffering from mental disorders. On paper, these systems appear to meet European norms. In reality, the resources are clearly insufficient in terms of both funding and staff numbers. This leads to inadequate treatment that can be detrimental to the dignity of the mentally ill prisoner. A series of reforms are progressively establishing a security-based management of mental illness. The criminalisation of people with mental health problems is becoming more and more systematic, while the number of individuals declared criminally irresponsible is generally decreasing. Public opinion is said to be suspicious or even hostile towards the mentally ill. People suffering from a mental problem who commit an offence are no longer seen as patients in need of care, but as dangers “which threaten or compromise the security or existence of somebody or something”. Leaving such a person at large involves risks. At the same time, psychiatric treatment has been developing in prisons. Theses facilities are viewed as a secure and economical means to “manage“ this population of ill persons that are reduced to a prisoner ID number.

The Belgian government is one of the forerunners of such securitarian vision, having introduced a system of so-called Social Defence in 1930. Persons recognised as exempt from criminal responsibility and requiring treatment are first placed in psychiatric annexes within prisons before being transferred to social defence facilities. The aim is not to treat them but to protect society from those deemed too dangerous. The European Committee for the Prevention of Torture (CPT) has highlighted inadequacies in the handling of people subject to internment measures and the lack of appropriate therapeutic activities. The European Court of Human Rights (ECHR) has also condemned the consequences of this system on the conditions of detention and internment.

The fate of mentally ill offenders varies from one country to another. They can be declared exempt from criminal responsibility if their condition impaired their ability to exercise appropriate judgement. In this case, they are subject not to a prison sentence but to compulsory care. However, judges in most countries may decide to impose a prison sentence in conjunction with a treatment order.

Germany applies the “twin-track” system. The offenders may, after their prison sentence ends, be subject to treatment order known as “preventive detention”. In Spain, when offenders are given a prison sentence with compulsory care, they undergo treatment first before being sent to prison. In the Netherlands, they complete two-thirds of their prison sentence before being sent to a psychiatric care facility.

Treatment orders are sometimes carried out within the prison facility itself. In Switzerland, persons subject to “in-patient treatment” can be placed in a correctional facility if it is judged to offer an appropriate level of care. However, as there is no specific units for mentally ill people, they remain in ordinary prison regimes. In the Netherlands, Penitentiary Psychiatric Centres (PPCs) are located within correctional facilities. They treat individuals subjected to treatment orders and other prisoners in need of care.

Conversely, persons found criminally responsible can be transferred to mental health centres. These facilities are not necessarily dedicated exclusively to individuals subjected to treatment orders. The judge can decide on such a placement in cases where a prison facility declares that it is unable to provide care for a prisoner. In France, Units for Difficult Psychiatric Patients (UMD) and Psychiatric Intensive Treatment Units (USIP) within general mental hospitals accommodate incarcerated persons, those declared criminally irresponsible when they require particularly important care, as well as general psychiatric patients.

In some countries, those who have been sentenced and those under treatment measures may find themselves sharing the same walls, whether in prison or in hospital. Persons with different legal statuses may be placed in the same units, cells or rooms.

A Belgian prisoner talks about his two fellow prisoners suffering from mental disorders: “I am going crazy, ma’am, with the other two in my cell… They have strange illnesses: one whines non-stop while the other one keeps yelling!”.

Almost all countries have psychiatric units or facilities dedicated to people who have been declared criminally irresponsible. These people are usually placed there by judges to fulfil the obligation of treatment order. These facilities combine health professionals and prison staff and depend, for the most part, on the prison administration.

The forensic psychiatric centres in Belgium operate on a mixed style of management. The prison administration manages security and infrastructure while the Ministry of Health oversees care. Patients are mainly supervised by prison officers. The CPT reported that their treatment prioritises security concerns over therapy needs. Spain and the Netherlands have mental health facilities in prisons. Prison officers monitor the premises. They do not have special training in dealing with prisoners with mental disorders.

The prison regulations are enforced in these institutions and leak into the management of care provision. For example, patients in Social Defence Sections (SDS) in Belgium, may be placed in solitary confinement for disciplinary reasons. The isolation takes place in the patient’s room. The CPT has underlined that this has no therapeutic justification. The Forensic Psychiatric Hospital of Seville in Spain is a former high-security prison infirmary. The disciplinary regime does not apply there, but many of its rules are inherited from the prison system: the use of mechanical restraints and solitary confinement is commonplace.

England and Wales chose not to create forensic psychiatric facilities dedicated to incarcerated persons or to individuals subjected to treatment orders. The latter are taken to a psychiatric hospital. The judge decides on such a placement when their allotted prison facility cannot provide them with the required level of care. Some offenders are placed in a “high security” psychiatric hospital where living conditions are almost the same as in a prison. Access to activities is limited and solitary confinement is a common practice.

The provision of psychiatric treatment in prison for people with mental health problems blurs the boundaries between care and punishment.

There are many people with mental health problems in prison. Some of these problems are known to the administration at the time of the individual’s admission, but the majority are detected only during their detention. Prison officers - informed by the prisoners – are usually the first to report the signs that a prisoner may have such an issue. They play a decisive role in identifying and supporting these people. However, training in the provision of care for people with mental disorders is rarely provided. When available, it is reduced to the bare minimum: a paradox, since prisons increasingly resemble psychiatric hospital units. The lack of adequate training of staff often leads in turn to inadequate support for prisoners who suffer from mental disorders. The European Court of Human Rights (ECHR) considers that this lack of care may constitute a violation of the Convention.

In Spain, the CPT observed that the prison guards in the unit for mentally ill women held at the Catalan prison of Wad-Ras do not receive any specific training. The CPT also reported acts of violence committed by officers of Puerto III prison against a mentally disordered prisoner. The latter was inflicted numerous kicks and blows, before spending eight hours under mechanical fixation in a face-down position.

In Italy, several prison unions condemn staff’s lack of training in the face of the high number of prisoners suffering from mental disorders. Some supervisors do not dare to intervene, for fear of worsening the situation.

In France, prison staff are not required to undergo any training on psychiatric disorders or their consequences. Since 2019 such training has been offered by the organisation Unafam, however the breadth of training is limited and registration is on a voluntary basis. Up till 2019, only training on prevention of suicide and self-harm had been provided. These shortcomings are not without consequence: in 2019, the Controller-General for Places of Deprivation of Liberty (Contrôleur générale des lieux de privation de liberté, CGLPL), the French National Preventive Mechanism, reported having seen “individuals with mental health problems [who] remained locked up in their cells, alone, without the intervention of a caregiver, on the grounds that ‘the patient had not requested [support]’”.

England has been offering a four-hour introductory training course on mental health to new correctional officers since 2016. No refresher course is planned for those already on the job. Additional training is generally cancelled due to the low participation rate of prison guards.

Belgium was condemned by the ECHR in 2017, following the death of a mentally ill prisoner who had been subjected to physical violence by prison officers. They had only received basic training on managing prisoners with mental disorders. A specific six-day module is now mandatory for all Belgian prison staff.

In Switzerland, prison guards undergo basic psychiatric training for about five days. Lessons are taught on different mental disorders and on suicide prevention. Staff who wish to do so can also take part in a 15-day training course on managing prisoners suffering from mental disorders. This course ends with a three-week internship in a psychiatric clinic.

All countries in this study recognise their obligation to provide medical treatment to prisoners and guarantee its continuity. However, their forensic mental health systems are generally deficient, with the principal culprit being the lack of available places.

In France, 26 Regional Mental Health Departments (SMPR) provide day-hospital care to prisoners with mental health problems. They accommodate between 1,500 and 2,000 prisoners a year, nearly 3% of the total prison population, whilst 22% are mentally ill. The medical team is responsible for offering treatments adapted to different illnesses. However, the waiting times for admission are generally long because of the large number of applications. This is compounded by the lack of available healthcare professionals: in 2016, 22% of the positions were left vacant.

Germany has psychiatric day units in six out of the 179 prisons in the country. In England, prisoners can sometimes wait for 27 weeks to access a one-to-one psychotherapy session. The Independent Monitoring Boards (IMB) highlighted over-high case-loads in treatment units in England as well as a lack of resources. More than 120 people were referred each month to the High Down Prison mental health unit. In Belgium, the waiting time for access to a psychological consultation can go up to nine months in certain prisons.

Care is generally limited to the bare minimum. National Preventive Mechanisms against torture (NPMs) in several countries point to a lack of adequate treatment. Pharmacological treatments are mostly given priority. In Italy, prison staff have condemned the excessive use of medication as a palliative for psychological distress. Nearly 28% of prisoners being treated are administered psychotropic drugs. In Belgium, doctors in several psychiatric units increased some prisoners’ medication to combat anxiety and stress during the prison staff strike.

The Netherlands are the exception: their forensic mental health system has been praised by the CPT. Each prison has an ”Extra Care Facility” (Extra Zorgvoorziening, EZV). Offenders with a mental disorder who are considered particularly vulnerable may be placed there. The EZV are governed by the same rules as the rest of the prison. An individual treatment plan is given upon entering the unit and prisoner-patients have access to many activities and therapies. The premises are decorated, specific activities are offered and prisoners spend a limited amount of time in their cells. Each of them is assigned a supervisor, who is a prison officer. Staff assigned to this part of the prison are specially trained. They work hand in hand with psychologists and social workers. The CPT considers EZVs to be very satisfactory and suggests that they may “serve as a model for other countries.”

Incarcerated persons suffering from mental disorders must, in theory, be transferred to a general psychiatric hospital if the prison cannot meet their needs. They rarely receive a warm welcome.

In Germany, most general psychiatric hospitals in North Rhine-Westphalia and Rhineland-Palatinate refuse to accept prisoner patients. Hospital staff say they fear for their safety and worry about the danger these people pose. In Spain, the government acknowledged the reluctance of regional authorities to make transfers from prison hospitals to general psychiatric hospitals: only 2% of patients were sent there when 30% of them met the criteria for transfer.

Incarcerated persons’ stays in psychiatric hospitals are relatively short. In France, they last two or three days. One prison psychiatrist testified: “caregivers keep [prisoners] for 24 to 48 hours and then send them back to us immediately. They are sometimes very sedated and given a very long medical prescription. When people come back to prison, they often start to experience the side effects of the medication, which have not been explained to them in the hospital. So of course, they stop taking it.”

In 2012, the ECHR condemned the discontinuity of care caused by prisoners’ recurrent back and forth trips between prisons and psychiatric hospitals in France.

Whether in prison, in a psychiatric hospital, or in a specific facility, solitary confinement measures for individuals suffering from mental disorders are extremely common.

In most countries, prisoners in a state of mental crisis are placed in solitary confinement pending their transfer to a psychiatric hospital. The waiting times for transfers are long, due to a lack of available beds. In England, prisoners can wait for up to four months.

In Belgium, persons placed in psychiatric annexes may be subject to solitary confinement for disciplinary reasons. The CPT “reported serious concerns about the use of isolation as a disciplinary sanction against persons with mental disorders”. In 2019, the NPM in France reported that prisoners were almost systematically placed in solitary confinement for their entire stay in psychiatric hospitals “despite the fact that their clinical status [did] not justify it”. This measure was imposed for at least twice as long as for other patients.
In England, long-term isolation is routinely used by health care personnel when the prisoner poses a “serious danger” to staff and other patients. Social contact is reduced to a minimum and patients leave their room for only a few hours a day, some for only 30 minutes every two days. Their isolation can sometimes last for several years.

Yet many studies point to the devastating effects of isolation on mental health. The lack of social contact, cramped cells or the fact of only being allowed to leave the cells very rarely all weaken mental health. The United Nations describes forced isolation as “cruel, inhuman or degrading treatment or punishment when used as a punishment”.

Many women offenders suffer from mental disorders. However, they face significant difficulties accessing specialised care. This discrimination is contrary to the International Convention on the Rights of Persons with Disabilities (ICRPD), which has been ratified by all the eight countries in this study.

In Belgium, they are denied access to psychiatric annexes. Women wait in ordinary prison regime for a psychiatric assessment before being declared criminally responsible or not. Women recognised as being criminally irresponsible are the only ones who have access to specialised units.

In France, only two SMPRs out of 26, in Rennes and Fleury-Mérogis, agree to take in women.

In Spain, mentally ill women in Wad-Ras are sent to the “polyvalent unit”, where they receive no treatment. The prison staff assigned there do not have any mental health training. The CPT stated that this unit “is not an appropriate environment in which to place women suffering from a mental illness”.