Psychiatry in Prisons: a Comprehensive Handbook is a collection of papers addressing, among others, various historical, legal, ethical, and psychological topics linked to prison psychiatry. Although the title might lead the unfamiliar reader to believe that the book focuses on practitioners conducting psychotherapy in forensic settings or providing psychiatric services, such assumption would only partially be correct. Most chapters focus on much broader issues, such as the strengths and shortcomings of the prison system(s); specific groups such as female prisoners, young or elderly prisoners, and prisoners with mental illness or intellectual disability; and overarching ethical dilemmas those working in prisons commonly face. Some examples of the ethical, legal, and personal dilemmas the chapters address are: consent to treatment, death in custody, and balancing best practices, which center around autonomy and beneficence, against the punishment and loss of freedom inherent in incarceration.
Although the geographical focus of most chapters is the United Kingdom, information pertaining to other countries is presented both embedded in the discussion of numerous chapters and also in two individual chapters dedicated specifically to exploring contemporary issues in the United States and New Zealand prison systems. The topic of the book is clearly significant, particularly given that in the last two decades, there has been a vast expansion of the number of people incarcerated in the United Kingdom (p. 210); that there is a high prevalence of mental illness among prisoners (p. 14); and that England and Wales have the highest number of life-sentenced prisoners in Europe (p. 22). For instance, around 70% of prisoners have a substance abuse or misuse problem, the suicide rate is five times higher among male prisoners than among their non-incarcerated counterparts, and some studies report that over 10% of prisoners have some form of psychosis and over 50% have a personality disorder (p. 25). Further, as is very well outlined in multiple chapters, the benefit of focusing on and improving psychiatry in prisons is multifaceted: such focus and improvements would benefit the well-being of the prisoners, society at large by reducing recidivism, and economies by reducing the social costs linked to released prisoners’ poor employment prospects. Accordingly, during recent years, there has been an increased focus “on the link between crime and health and how addressing one can reduce the other” (p. 50).
Prison psychiatry has come a long way compared to the eighteenth century when prisons were “filthy, corrupt-ridden, and unhealthy” (p. 9); when the doctor’s role was, in accordance with the then accepted principle of punishment (as opposed to rehabilitation), to determine the minimum food required to sustain a prisoner’s life (p. 11); and when it was thought that criminal propensities were contagious (p. 12). Today, prison services account for prisoners’ needs (specific to their offence), education, training, and resettlement (p. 19). Although the aforementioned improvement did take place, there still appears to be room for progress because “psychiatry has failed to address itself properly to the question of what is its role in prisons” (p. 15). A specific problem is that mental illness often goes unrecognized in prisons (p. 31): in one prison, less than half of those with a psychotic or mood disorder received treatment (at the time of the study). Finally, transfers from prisons to hospitals (even when such transfer is “urgently needed”) take several months and imply a delay of over 100 days (p. 47).
Overall, most chapters of the book are very well-researched, are written by experts in the respective topic (e.g., the chapter on prison inspection is co-authored by the former head of Healthcare Inspection at HM Inspectorate of Prisons and the former Deputy Chief Inspector of Prisons for England and Wales) but some could benefit from either a more thorough investigation of the empirical literature or a more in-depth exploration of arguments. For instance, in the chapter on hunger strikes and food refusal, the author(s) argue that no person has developed an eating disorder because of fasting. There is evidence to the contrary, as studies show that numerous persons who are diagnosed with Anorexia Nervosa originally start dieting for a benign cause such as a spring vacation or athletic competition (e.g., Lock & Kirz, 2008). Over time however, weight loss becomes an end in itself, spiraling out of the patient’s control and consequently contributing to the maintenance of the disorder (Lock & Kirz, 2008; Stice, 2002). As another example, the chapter on elderly prisoners could benefit from an incorporation of findings from empirical studies that address criminality and its relationship to ageing [e.g., similarly to the severity of most personality disorders, Harpur and Hare’s (1994) findings according to which the psychopathy of those who score high on Factor II of the Psychopathy Checklist decreases with age as opposed to the psychopathy of those who score high on Factor I, which remains stable over time].
Also, multiple chapters address the issue of heightened prevalence of mental illness in prisons and present different theories that explain the causes of such prevalence. Some of the authors draw on philosophy (e.g., Foucault) and some address the difficulties inherent in establishing temporality and causality between mental illness and offending. Although currently, Psychology and Psychiatry account for factors such as deviance, functional impairment, subjective distress, and statistical infrequency as relevant criteria of mental illness, none of these factors have led to a consensus on what constitutes psychopathology. Given this lack of unanimity in opinions and the obvious link between the abovementioned factors and the institution of imprisonment, an interesting point that could be discussed in one (or more) of the chapters is the currently agreed-upon definition of mental illness (or lack thereof). One author, for example, argues that “whilst we deny it, prisons were always to do with confining the undesirable elements of society, psychiatric patients as well as criminals” (p. 44). The question linked to our definition of mental illness thus becomes inevitable: Do we confine these persons in prisons because they are criminals, or do we define criminality based on behaviors that warrant imprisonment?
In terms of the technicality of the chapters, most authors employ a fairly sophisticated language. In other words, some basic understanding of (medico-)legal terminology, medical illnesses and mechanisms that underlie human psychological functioning are necessary for a full appreciation of the chapters. Probably, the most “clinical-psychological” chapter is the one on sex offenders and vulnerable prisoners. This chapter outlines and explores in detail interventions for sex offenders, risk factors that predispose patients to committing sexual offences (e.g., distorted thinking patterns, interpersonal functioning, and emotion regulation), and diverse treatment styles and assessment.
Psychiatry in Prisons provides a balanced picture of the issues related to prison psychiatry, even focusing on research and methodological challenges to studying mental illness in prisons. Thus, Psychiatry in Prisons is an excellent source both for researchers and for budding practitioners. However, not only those with an academic interest in prison psychiatry, but those working in prisons; those interested in the history and development of the mental health care of prisoners; and those who seek information on the basic legal and ethical matters pertaining to the psychiatric care of this population would likely find Psychiatry in Prisons fascinating and intellectually challenging yet fulfilling. Finally, Psychiatry in Prisons could both be used as a textbook in a graduate-level (perhaps forensic) psychology course and as a book whose purpose is scientific popularization.
Harpur, T. J. & Hare, R. D. (1994). Assessment of psychopathy as a function of age. Journal of Abnormal Psychology, 103, 604-609.
Lock, J. & Kirz, N. (2008). Eating disorders: Anorexia nervosa. In W. E. Craighead, D. J. Miklowitz, & L. W. Craighead. (Eds.), Psychopathology: History, diagnosis, and empirical foundations (467-495). Hoboken, NJ: John Wiley & Sons, Inc.
Stice, E. (2002). Risk and maintenance factors for eating pathology: A meta-analytic review. Psychological Bulletin, 128, 825-848.
© 2011 Nora Bunford
Nora Bunford is pursuing a PhD in Clinical Child Psychology at Ohio University. She received her B.A. degrees in Psychology and Philosophy from Southern Illinois University Carbondale and her M.S. degree in Clinical-Counseling Psychology from Illinois State University. While completing her doctoral studies in Psychology, Nora is also concurrently pursuing a master's degree in Philosophy. Her academic interests center around Bioethics, Psychology and its theoretical underpinnings, and research science. E-mail: [email protected]