Providing support in the justice system

Dr Kathleen Levick, an ST4 intellectual disability psychiatrist based in South London, reflects on her experiences getting to know inmates and defendants in the criminal justice system.

When I started working as an intellectual disability (ID) psychiatrist, I knew it would be varied – but I didn’t think it would lead to me wandering around one of London’s biggest men’s prisons. In my weekly special interest sessions, I spent over a year doing ADHD assessments for the inmates, which equipped me with a heavy set of keys jangling inside a pouch on my belt.

A unique and rewarding environment

Working in a prison was certainly a very different environment to one’s usual cosy clinic room (yes, even NHS rooms are cosy in comparison!).  It can be an intimidating setting, until you get used to it, and even then sometimes it’s tough.  You might see someone in the prison clinic rooms, but more often, you have to go onto the wings and take what opportunity you find to see the inmates – sometimes through the door of their cell, or in whatever (relatively) quiet space you can grab for a few minutes.

As you might imagine, it was a busy, noisy, sometimes slightly chaotic-seeming environment. This of course, was all the more challenging for my cohort of patients.  Attention Deficit Hyperactivity Disorder can make a person quickly distracted, impulsive in their actions, and unable to sit still for long or keep their attention on your questions. 

Navigating prison culture

There’s sometimes a stigma attached seeing a doctor, especially a psychiatrist, as psychiatrists often unfortunately still find. I found that there were some people the inmates were more eager to see – someone with the power to influence their privileges, accommodation or job prospects within the prison.  Sometimes, they were unwilling to engage with someone they saw as part of the authority and hierarchy that dictated their days.

Alternatively, sometimes were glad to see me. In prison, days are long with much of them spent in one’s cell – depending of course, on what your offence may have been, which category wing you are on, or what activities you are able to take part in.  There were challenges: some inmates saw sessions as an opportunity to gather mitigation with regards sentencing, if they were there on remand.

Prescribing in a difficult climate

There were also concerns amongst staff about diversion of prescribed medications, especially some of the stimulant medications we might prescribe for ADHD.  This can also raise prescribing challenges, especially if complicated by inmates issues with substance misuse.

By and large though, in my experience, diversion of medication wasn’t a large problem.  Some men were looking to make use of the relative stability of being in prison to restart treatment that they may have had in the past, but somehow strayed from (the unpredictability of some people’s life experience is eye-opening, even after the years I have already spent working with people from all walks of life).  Other men had always felt that there has been ‘something different’ about them, telling me the things that they found harder than other people. They nodded emphatically when I described the core symptoms of ADHD, and they often recognised, in these symptoms, some of the traits that brought them into the position they were in.

Rays of hope

One man I have in mind is not long 18, and now in the adult system.  He had always been in trouble, labelled ‘naughty’ or ‘bad’, excluded from school, impulsive and easily led into pranks and ‘foolishness’ (his words). He had a habit of – quite literally – not looking before he leapt, leading to broken bones in the past, and finally prison. 

No one mentioned ADHD to him before, but when he thought about it, an uncle had similar characteristics to those we discuss. The thing is, he was sweet, easy to talk to and reflective about what had led him to being in prison for the first time.  He told me evenly about difficulties growing up, the instability caused by frequently changing schools, and the influence of certain family members (though now he has a core of important people who are there for him, in his mum and his nan).

Though he found it difficult to sit still in the chair –getting up a few times to investigate noise through the door window – he was keen to return to talk to me. On hearing the potential benefits of medication, he was eager to explore this opportunity to potentially change the direction his life and relieve his ever-shifting attention (of course, there are also psychological, social and educational interventions that psychiatrists would recommend, but in prison, another over-stretched, under-resourced system, access to these can be slow and sparse, even with the best intentions).

He was enthusiastic and full of hope and promise for a different future, learning his lesson, making this his first and last time in prison, making the best of the romantic relationship that (hopefully) awaits when he gets out, maybe getting some qualifications, maybe even using his experience to be able to guide others, of whom he has seen many, treading a similar path to his own.

The challenge of closure

Of course, there were some for whom I started treatment that I wouldn’t get to see in follow-up, and that’s was one of the hard things.  In prison, someone might be there on remand, or may be transferred to a different facility.  There are some that you may start on medication, and then hear that they have been released, only to see them back in a few weeks later – they stopped taking their meds, they went back into their old environment, lacking in stability and boundaries that are present in the prison (for all its difficulties) and slipping back into the old habits, acquaintances, temptations and threats of life outside.

There are some, though, that I saw again, who told me how much calmer they were feel taking the medication, how they managed to walk away from that situation that would have drawn them into trouble in the past.  I saw in front of me someone who could sit stiller than before, could hold attention through our meeting, was better able to regulate angry outbursts.

Some of the people, like my 18-year-old, I didn’t see again, but I hope that he was able to fulfil his ambitions, to halt the potential revolving door back into trouble and maybe back into prison.  Of course, not everyone with ADHD ends up in this particular trap, though educational and social opportunities can be missed, highlighting the importance of this condition being caught early and appropriately treated. Early intervention can change the course of someone’s life.

People ask me how I managed such an unfamiliar environment, and told me to be safe. However, my overarching experience, despite interacting with some people who undeniably had done bad and dangerous things, was that ‘there but by the grace of God…’.  My placement underscored to me the privilege of my existence, the overall stability I have experienced in life and health, the educational and social opportunities that have been afforded me.

Moving on

My time at the prison has come to an end for now. I have moved on to a special interest project researching court diversion for those with intellectual disabilities.  Court diversion exists already for those with mental health issues, those who might be better served by psychiatric input rather than – or in conjunction with – a custodial sentence. 

In my new role, we sometimes make recommendations to the court regarding appropriate reasonable adjustments, or divert a person to hospital or community treatment rather than prison, if more appropriate.  So far, a specialist provision for those with intellectual disabilities, neurodevelopmental issues or autism spectrum disorders does not exist or certainly is not wide-spread. 

With the insight gained over my time in the prison, I am aware of the vulnerabilities that such patients might face if convicted and imprisoned. Some will still go through that experience, though hopefully we can advise appropriate measures to support their needs  and maybe to prevent recurrences.

It has been a privilege to have this experience, and it has reminded me, yet again, of something that strikes me about psychiatry in general: it is sometimes challenging, but rarely dull.