A court-focused model of forensic psychiatry provision to central London: Abolishing remands to prison?

Delivering psychiatric care to prisoners: problems and solutions

‘In some few jails are confined idiots and lunatics, –many of the bridewells are crowded and offensive, because the rooms which were designed for prisoners are occupied by lunatics. The insane, when they are not kept separate, disturb and terrify other prisoners. No care is taken of them, although it is probable that by medicines, and proper regimen, some of them might be restored to their senses, and usefulness in life’ (Howard, 1784: pp. 10–11).

Diversion of mentally disordered people from the criminal justice system in England and Wales: An overview

The form that diversion mechanisms take in a given jurisdiction will be influenced both by mental health law and sentencing policies, and by the structure of criminal justice and health care systems. In England and Wales, treatment in hospital in lieu of any other sentence is available as a disposal option following a finding of guilt. In addition, there is a National Health Service, free at the point of delivery, the existence of which creates the potential for a co-ordinated nationwide response to mental disorder within the criminal justice system. In recent years, the National Health Service has taken over the delivery of health care in prisons, including psychiatric services, with the principle being one of equivalence between the quality of health provision provided in the community and that provided in prisons. However, problems within the system dictate that an important place remains for add-on diversion initiatives at courts and police stations, which aim to circumvent some of the delays in dealing with mentally disordered people or to prevent them entering the criminal justice system in the first place. It has been demonstrated that such mechanisms can be highly effective, and a government-sponsored review in 1992 recommended their general adoption. A lack of central co-ordination determined that progress was very slow. A new government-commissioned report in 2009 set out detailed recommendations for reform throughout the system. It laid emphasis on a co-ordinated response at all levels and between all agencies, and placed importance on linking initiatives with community services and with preventative measures, including attention to the effects of social exclusion. Some grounds for optimism exist, although there are particular problems in implementing change at a time of financial austerity.

Pretrial court diversion of people with mental illness

Court diversion is a method of administering justice compassionately for persons with mental illness (PMI). Evidence-based practices of this intervention were identified by reviewing the existing literature. Findings suggest that: (a) formal case finding procedures are important for the early identification of mentally ill offenders in need of services, (b) stable housing enhances the possibility that the divertee will remain in regular contact with her or his treatment provider, and (c) active case management improves compliance and reduces the likelihood of recidivism. In summary, research has not yet yielded generalizable knowledge about diversion and thus, it is suggested that evaluations should involve well-defined indicators, benchmarks, and outcomes.

Court diversion in perspective

Court diversion schemes have been running for a decade in New Zealand and are increasing in number in Australia. This paper aims to give an international and historical context to these developments, by reference to psychiatric initiatives at courts in the US and in England and Wales. From a review of the specialist literature, an account is given of three forms of psychiatric intervention in courts over the last 90 years: court psychiatric clinics and mental health courts in the US, and court diversion schemes in England and Wales. High levels of psychiatric morbidity among prisoners, coupled with a continuing increase in prisoner numbers, demonstrate the need for systems for dealing with mentally ill people who come before the courts. Court diversion in England and Wales developed as part of a system where the mentally ill who are found guilty are sent to hospital in lieu of any other sentence. Its focus is on a form of psychiatric triage, and its ethos is the health of the patient. Court psychiatric clinics in the US grew up as an alternative to assessment in prison. Their focus has been on full psychiatric evaluation in an insanity and incompetence jurisdiction. The ethos has been that of serving the court. Mental health courts are heavily influenced by ideas of therapeutic jurisprudence, and their emphasis has been on a judge holding minor offenders in community care through the threat of judicial sanction. Experience in England and Wales has shown that court diversion can be a powerful and effective intervention. In order for it to function properly, those running court schemes need direct admission rights to psychiatric beds, both open and locked. Court diversion schemes are best as part of a spectrum of services to police stations, courts and prisons, which involved both general and forensic psychiatrists.