OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Prison inmates with major mental illness, a Norwegian challenge, also a

Nordic?

Pål Hartvigpaal.hartvig@kompetanse-senteret.no

Centre for Forensic Psychiatry,

Oslo University Hospital,

Oslo, Norway

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Meta-perspective 1 (of 2):Size of prison vs. mental hospital sector

”Penroses law” (Penrose 1939) ”Inverse relationship between hospital and prison beds in all studied European nations, including Nordic”

”The law” proven robust also in longitudinal studies up to now (Hartvig&Kjelsberg 2009), though mental deinstitutionalisation e.g. not found guilty of the increase in homicides, same in other countries (e.g.Gunn 2000, Wallace et al. 2004)

Still probably causing increase in psychotic prisoners

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Prevalence in prisons of MMI

Trans-nationally: 4 % psychotic, (including psychotic depression) (Fazel&Danesh 2002)

In Norway seemingly corresponding occurrence (Kjelsberg, Hartvig,Østberg 2004, 2005).

In Denmark (Andersen et al. 1996, 2004) But: Tells little about the real percentage of insane

prisoners in a nation’s total population, example: USA ten times higher incarceration rate than Norway; if(?) same prison prevalence, ten times higher national percentage

”America’s new mental hospitals” (Torrey 1995)

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

The ”Import model” of Norwegian prison health service, since 1988

Health services not ”owned” or administered by prison authorities

Consttutes a well functioning general health care for all prisoners

All prisons have attached psychiatric teams responsible for service, in the larger on a daily present basis

A much higher portion of prisoners than in general society are offered psychotherapeutical sessions. Still; increase and enhancement desirable

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Norwegian status; psychotic prisoners

4 % means circa 90 actively psychotic detainees;humanitarian disgrace or just a problem?

Crim Proc Code: ”Psychotics unfit for serving”, ”Standard international doctrine”

De-dramatizing factors: Short stay, take medication Still too many, creating unease and partly conflict Main problem: Those psychotic, unconsenting to

medication; coerced tratment is unlawful and unworthy outside mental health system

Such patients often admitted, but quite many primarily rejected or too quickly returned

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Norwegian status

Easy to understand both sides in the ”conflicts” ”Psychiatry”: a)too small bed capacity in a system

75 % reduced in 30 years, b) difficulties with custodial demands for prisoners, c) easier to discharge to prison control than to society

Prison: ”Don’t belong here, great strain for prison officers, unjust and a social disgrace”

Possible solutions: a) Definite growth in general psychiatric bed institutions; impossible! b) return to very limited establishment of ear-marked ”asylum wards” in Crim Just System; more possible

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Meta-perspective 2: What about prisoners with serious mental, but not psychotic(or gravely mentally retarded) disorders? PD’s serve in hospitals?

l Most countries practise a clear demarcation line; psychotic or not?, related to the ”insanity excuse”, both to sentencing to and serving in prison

In last decade emerging discussion about ”free will” and its opposite ”determinism”; in Philosophy, Law, Psychology, Psychiatry and Neuroscience

New field: Neuroethics. Determinists claim; not only psychotics be excused, but also

serious personality disordered including psychopaths, because of very limited free will

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Neuroethics, implications

Basis: Biochemical findings and especially brain scanning (PET,MRI) showing strucural and functional defects, especially ventromedial prefrontal cortex and amygdala

Giving strong, at times uncontrollable drives and urges, approaching the free will to almost zero

Some determinists propose the ”insanity excuse” to be strongly expanded to comprise such disordered persons

Where could these be controlled/treated?

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Neuroethics, implications

Convert a large portion of prisons to psychiatric institutions?

Not in accordance with ”folk psychology” and be rejected by a strong societal majority.

Likewise by the psychiatric profession, because of very low treatability of ”psychopathy-near PD” (e.g. Kernberg 2007) and custodial problems

Pragmatically, the ”insanity excuse” will prevail regarding diversion from prison to mental institution

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Neuroethics, implications

Still, the ”free will vs. determinism” discussion should lead to: Reduction of a moral and retributional condemnation in our dealing with mentally disordered, not psychotic criminal perpetrators

OsloUniversity Hospital

HELSE SØR-ØSTwww.forensic-psychiatry.no

Thanks for the attention

Pål Hartvig

paal.hartvig@kompetanse-senteret.no

Centre for Forensic Psychiatry,

Oslo University Hospital,

Oslo, Norway