Services in Prison for Victims of

Abuse: Issues and Options

Annie Bartlett
St Georges
University of London
Women In Prison
Concepts
Clinical Issues
Care Delivery

What should we offer?

Why?
Women In Prison: Criminology
Women as a percentage of total prison
population

England and Wales 5.6%
US 5%
Australia 6.4%
New Zealand 4%

Women In Prison: Criminology
Absolute numbers of women in prison small in
England and Wales i.e. 4447 in October 2006
Absolute number rising
Percentage of women as a proportion of the
total prison population rising
Modest contribution to offending and very
modest contribution to serious offending
Women In Prison: Criminology
Womens contribution to serious offending
Murder 6%
Attempted murder 1.5%
Manslaughter 16%
Woundings 7%
Sexual Offences 1.3%
Women In Prison: Criminology
75% of women in prison have not been there
before
Many on remand will not go on to receive
custodial sentences even though the chances
of receiving a custodial sentences are higher
than ever
Custodial sentences are short


Women In Prison: Concepts
Mad and bad

Vulnerable

Hard to help

Draining for staff

Women in Prison: Concepts
Mental Health
Substance Misuse
Trauma
Social Circumstances

- helpful re focused interventions
- this also represents an artificial separation
of meaningfully linked problems
Women in Prison: Mental Health
Psychosis 14%, Personality Disorder 50%, Hazardous
Drinking 40%, Drug Dependence 54%(remand), 41%
(sentenced)
These problems are mainly associated with non-violent
offending although there is a correlation between
violent offending and psychosis
50 women at a time are persistent severe self
mutilators
In the US co-morbidity for severe mental disorder and
substance misuse is higher than in the community

Women In Prison: Substance
Misuse
Women use harder drugs than men, 2 in 5 inject
More likely than men to say drugs alleviate physical
and emotional pain
High rates of physical and sexual abuse as children
and adults
Increasingly seen as a maladaptive coping mechanism
rather than an isolated clinical phenomenon
7000 women in 2005/6 in touch with clinical
services,the same enumber in touch with CARATS
teams. Women more likely than men to seek help,
complete treatment and be satisfied with the service
Women In Prison: Trauma
Histories of trauma poorly documented in UK
studies
Clinical PTSD linked with substance misuse
In the US PTSD was the second most common
diagnosis after substance misuse/dependence
Mental health service contact correlates with
CSA,family disharmony and co=morbid
substance misuse in the US
Women In Prison: Social
Circumstances
Loss of accommodation
No GP
Childcare responsibilities (Disruption to childcare: two
thirds of women in prison are mothers, 55% have a
child under 16yrs. 23% of those with dependent
children had a partner caring for the child, 52% relied
on relatives, 12% on foster parents/care)
Poor educational attainment
Poor work histories
Women In Prison: Policy Initiatives
1999 National Service Framework
1999 Joint Report on the Organisation of Prison
Health Care
2001 Changing the Outlook: a Strategy for
Modernising Mental Health in Prisons
2000 NHS Plan
2002 Womens Mental Health: Into the Mainstream
2002Mainstreaming Gender and Womens Mental
Health 2003


Women In Prison: Policy Initiatives
2006 Women at Risk 2006
2006 Tackling the Health Effects of Domestic and
Sexual Violence and Abuse
DoH National Pilot in Mental Health Trusts of SATs
(Sexual Abuse Teams)
HMPs Women and Young Peoples Group: Womens
Mental Health Group
2007 Baroness Corston Review of Women and the
Criminal Justice System
Women In Prison: Policy Principles
Equivalence
Gender sensitive
Holistic

Important Questions
To what extent has policy been translated into
practice?
Does that make any difference and if so to what?
Women In Prison: Care Delivery
Number of self-inflicted deaths in custody has fallen
Prison health taken up by the NHS and this is
anecdotally thought to have brought improvement
Suggestion now is for radical prison in the community
with services for substance misuse and mental
health
Minimal treatment evaluation published: Small DBT
study for Borderline Personality Disorder women N=16
showed improvement
Women In Prison: Care Delivery
Evaluation
US studies: substance misuse
Single issue treatment often more holistic
Completed Substance misuse treatment 1-
2year FU less re-offending
Gender specific programmes have better
completion rates
Changed accommodation post release
promotes abstinence


Women In Prison: Care Delivery
Evaluation
US: trauma
Seeking Safety Pilots for severe and early
onset trauma reduced drug use and rates of
PTSD
Trauma Incident Reduction programme
reduced some trauma symptoms and
depression and anxiety
Women In Prison: Care Delivery
Is it designed to make women better ?
Is it designed to reduce re-offending?
To what extent are these issues actually
linked?
Does it achieve any of these things?
Is it cost effective ? Or does the burden of care
simply shift to other agencies that might be
more expensive?

Women in Prison: Care Delivery
Holloway
Health Care: mental health (secondary and
tertiary care) substance misuse(secondary
care) primary care ( including mental health)
Significant input from voluntary sector
organisations
Programmes run by forensic psychology
(prison)
Women In Prison:Care Delivery
Mental health:
Asessment Unit: mental illness and assessement of
severe self harm
Inreach team would like to be an SMI service
Consultant Psychotherapist
Tertiary forensic input ( psychologist and psychiatry)
Work closely with discipline staff especially the safer
custody lead

Women in Prison: Care Delivery
Primary Care:
Counselling psychology and CIP
GPs plus GP with an interest in mental health
Women in Prison: Care Delivery
Substance Misuse:
50% of women entering Holloway require
complex detoxification
CARATS re follow on care
Nationally NTA data suggests in 2005/6 7000
women in touch with clinical services, same
number in touch with CARATS. 577 went into
rehab,419 completed
Women In Prison: Limitations of
Current Care Delivery
Unmet need poorly characterised and quantified- the
epidemiology and levels of self harm suggests we offer
little to those likely to have trauma histories, currently
abusive relationships and maladaptive coping
mechanisms in adverse social circumstances
Recent scoping exercise indicated that a service going
beyond the walls was desirable- life skills, self esteem,
support for more constructive relationships
Short lengths of stay and unpredictable lengths of stay
pose a challenge for anyone including those of existing
CPA
Women In Prison: Future Options
We are not offering a service that recognises either the
interconnectedness of womens problems nor the
barriers to getting help
Our plan
- prison without walls counselling and
psychotherapy
- intervention study re PTSD and Substance
misuse (Seeking Safety Programme)
Women In Prison: Constraints on
Improvement
Government agenda on risk and reduction of
offending
Escalating numbers of prisoners
PCTs funding issues
Attitudinal issues in the health service that
have difficulties looking at complex need