Nearly half of all inmates in New South Wales have a mental illness, but there is a desperate shortage of beds in prison mental health units and decisions about their care are left in the hands of prison guards with little or no training in mental health.

The result, according to a former senior assistant commissioner for Corrective Services NSW, is a punitive prison system and a growing population of unreformable criminals.

Catriona McComish served for 13 years in several senior roles at Corrective Services, including five years as director of psychological services. She says that prison, by its very nature, cannot rehabilitate people with mental illnesses.

“The position that I came to in the end … [is] that many of [the programs] were impossible to run effectively in the correctional framework because the emphasis was always about security and risk — in terms of risk of escape or risk of violence within the centres — and that often clashed with what was the therapeutic need,” McComish told Crikey. Offenders with mental disorders — more than 40% of NSW prisoners — have more than twice the difficulty reintegrating into society, she says.

“We’re creating that situation where … that population is just going to continue to cycle back into prison. They will not get the kind of services they need in prison in order to address their mental health issues and, upon their release, they will have little opportunity of accessing services,” she says.

“If they’re going to have their mental health needs addressed, [they] need to be removed from the prison system.”

McComish worked on several initiatives intended to help address the more urgent mental health needs of prisoners. During her time at Corrective Services, specific programs and purpose-built crisis support units were set up at Long Bay, Bathurst and Cessnock correctional centres for inmates at high risk of suicide. But these initiatives never succeeded in reaching the population or serving the purpose for which they were intended, she says.

“Because of … concerns about security, the design of the units was changed … The population that they were there for, that was changed … In the men’s system a couple of those crisis support units were closed. The longer-term unit at Long Bay was closed for a significant period of time and then its purpose was changed …  And in the women’s system it seems to happen even prior to units getting operational,” said McComish, who left the department in 2006.

“It’s kind of like because the purpose of the prison is very different [to the purpose of the units], it seems impossible to maintain a … response to the mental health needs.”

Long Bay Forensic Hospital — which is run by a part of the Department of Health called Justice Health, rather than by Corrective Services — is a step in the right direction, McComish says. The hospital takes forensic patients — people found not guilty by way of mental illness — out of the criminal justice system and treats them in a purpose-built hospital environment.

But NSW has more than 340 forensic patients and Long Bay Forensic Hospital has only 135 beds, which leaves about 200 forensic patients in the care of prison staff rather than healthcare professionals.

Moreover, the figures don’t account for the thousands of prisoners who are not forensic patients, but have acute mental health needs. According to the Justice Health website, additional beds dedicated to the mental health treatment of prisoners are provided at the Long Bay and Silverwater correctional complexes. Long Bay Hospital has 95 mental health beds operated jointly by Justice Health and Corrective Services; the Metropolitan Remand and Reception Centre at Silverwater has a 40-bed mental health unit for men; and Silverwater Women’s Correctional Centre has a 10-bed mental health unit.

These 145 beds are intended to accommodate the mental health needs of the state’s 11,000 prisoners, about 8500 of whom have at least one psychiatric disorder, according to the latest data from Corrections Health (now Justice Health). The study, published in 2003, found that about 77% of the state’s inmates have a psychiatric disorder of some kind (this includes substance use disorders, personality disorders and mental health disorders); 42% have a mental health disorder; 36% have an anxiety disorder, and 22% have an affective disorder such as depression.

The paucity of dedicated mental health facilities for NSW prisoners means the burden of caring for this severely disturbed population falls on the state’s custodial officers, the majority of whom have not had any training in mental health. Said McComish: “It’s a problem with the way that the whole justice system is working that you end up with a situation in which you have people with mental illness and mental health problems locked up with guards who are not trained to actually manage those needs.”

The issue, she says, is that officers are dealing with a skewed population living in extremely tough conditions. Among this population are those with serious diagnosed and undiagnosed mental health problems, as well as others who are “just wanting to escape from the reality they’re in” through medication, for example.

“And so you’ve got correctional officers who have to make some kind of distinction about that — about when there is a genuine need and when there is a need just for some kind of amelioration of the stress. That’s the leeway that they have and of course at times you’re going to have officers who pay out in some way,” she says.

Corrective Services NSW, however, denies the existence of any such leeway. When asked how much discretion custodial officers exercise in responding to inmate requests for medical assistance, spokesperson Candace Sutton said: “No discretion. If an inmate has a health problem and they want to see a professional, the custodial person has to get them one or make an appointment or something with Justice Health — whatever is appropriate.”

Sutton added there are no circumstances under which officers have the right to deny an inmate’s request for medical assistance and that custodial officers are duty bound to contact Justice Health when there is a request. Justice Health provided a written statement in response to enquiries about its mental health services and relationship with Corrective Services:

“The high proportion of mental health problems within the NSW correctional environment presents challenges for Justice Health. Justice Health provides … one of the most comprehensive in reach correctional mental health services in Australia. Justice Health works closely with Corrective Services NSW to educate and train correctional officers in the identification of mental health problems. These training programs provide correctional officers with an understanding of the nature of mental illness and how best to engage with people suffering from a mental illness.”

But Matt Bindley, chairman of the Prison Officers Vocational Branch of the NSW Public Services Association, the union representing prison officers, tells a different story. A prison officer of 17 years standing, Bindley says that he has never received any mental health training. “And I know that the vast majority of officers that work in the general population prison don’t either,” he added.

“The staff don’t receive enough training in relation to mental health issues at all. The real problem is that each person [inmate] has their own individual problems and I just don’t think there’s enough time, resources or money to provide the adequate training,” Bindley says. Custodial staff “undoubtedly” exercise discretion when making decisions about whether prisoners should be granted access to medical personnel.

“Custodial staff are the first point of contact and they can make a decision themselves as to whether or not they feel an inmate should be seen by the clinic staff or referred to a psychologist,” says Bindley, who does argue the lack of mental health training is “probably not an overwhelming problem”.

“I think overall a lot of the staff are very good at their job and have the ability to identify when something isn’t right with people,” he says.

Asked how prison officers who have received no mental health training are able to identify mental health problems and appropriately assess whether an inmate should be granted access to Justice Health staff, Bindley says it is a skill officers learn on the job: “I think over a period of time staff develop the ability to deal with people. It’s the interpersonal skills that you develop and you just — you know when somebody’s presenting and they’re not quite right. You know, you can see that they may be physically distressed and emotionally distressed. They present in different moods — mood swings, ups and downs.

“It’s just something that you learn through time, you know, through doing the job day in and day out, you know how to deal with people.”

However, several sources — namely, ex-prisoners and medical professionals who have worked in prisoner health, the NSW Ombudsman and the findings of investigations of deaths in custody — strongly suggest that at least some custodial officers do not always respond appropriately to inmates’ mental health needs. Professor Michael Levy, a public health physician who worked in NSW prisoner health between 1997 and 2006, says prisoners and their health needs are very much at the mercy of custodial staff.

“Without a doubt the custodial staff are the gatekeepers. They hold the life and welfare of the detainee very, very much in their hands,” said Levy, now the medical director at ACT Corrections Health. “In the most humane prisons and in the cruelest, it’s the prison officers and uniquely the prison governor who has control over everything that goes on … It is a very, very oppressive institution. It runs risks for society and comes up in coroner’s findings periodically just how powerless prisoners are.”

According to Jennifer (not her real name), a mother and university graduate who spent six weeks at Silverwater Women’s Correctional Centre (formerly Mulawa) earlier this year, custodial staff exercise discretion based on personal bias “every single day”.

“It’s possibly the most barbaric treatment of people I’ve ever seen,” she told Crikey. “I saw them refuse people access to welfare, access to doctors, access to nurses. I was refused medical treatment while I was in there; I was refused access to a telephone. I wanted to call the Ombudsman. After I said I wanted to call the Ombudsman they specifically refused to let me out of the cell.”

Jennifer says inmates with mental health problems are routinely mistreated by prison staff: “There was a certain level of public mocking that would happen. There were some people who were singled out because of their obvious symptoms for humiliation by guards. There was one girl who was quite outspoken and had some pretty serious self-harm tendencies and she was singled out and put on show by the officers quite frequently.”

Robert Barco, who was released from prison last year and is now a project manager with Rockdale Community Council, has spent more than 23 years in NSW prisons. While he denies ever having seen custodial staff humiliate inmates with mental health disorders, he says staff often restrict or deny inmates’ access to health care in response to personal disagreements.

“I remember one guy was giving them such a hard time. He was on pills and methadone, and I remember he was locked in his cell and he didn’t leave the cell for two days to go and get his medication. The excuse they used was that he had no ID card so … they actually denied him that medication,” he said.

“On the third day, myself and [another inmate] intervened and went to the officers, and asked them to open the cell. We searched the cell and found his ID card, and I said to one of the rovers [custodial officers]: ‘If you don’t give him his medication now, I’m going to ring the Ombudsman and complain’, … [I said to them] that it was now the third day and he would be in severe withdrawal from the methadone.

“The issue he had was with one of the officers … The guy [the inmate] was an assh-le and created a lot of problems for him [the officer], but enough’s enough … I think this guy [the inmate] had a lot of issues, a lot of mental issues.”

This incident at Long Bay Metropolitan Special Program Centre in 2008 is one of the clearer examples of officers exercising personal judgement in health-related issues. Other forms of mistreatment, such as verbal abuse, are less vindictive but more common, says Barco.

“They [inmates with mental illnesses] can be quite hard to look after too because some are just like little children … They will pester the staff … and I think for some of the custodials it gets to them, gets them quite frustrated. [Staff] will use terms like ‘f-cking bloody mental bastards’ and terms like that. I guess it’s out of frustration,” he said.

The NSW Ombudsman refused to comment on complaints it receives about Corrective Services staff. But its 2008-09 annual report notes: “Many of the complaints we have received this year from inmates concern bullying and harassment by correctional centre staff. Some of these complaints have involved allegations of … derogatory comments being made about the intellectual capacity of inmates.”

According to the document, “officer misconduct” was the third-biggest grievance reported by inmates in 2008-09. The Ombudsman also voiced particular concern with “an increase in the number of inmates claiming to have suffered detrimental action after contacting us with a problem, or who are reluctant to report serious misconduct for fear of retribution. Many inmates have reported allegations of serious misconduct by staff to us but, because they do not want to have their name associated with the complaint, it is difficult for us to be able to take further action.”

Even beyond specific incidents or bullying or abuse, the mentally ill are likely to find themselves at a distinct disadvantage in the prison system, an environment where personal relations — between inmates, as well as between inmates and Corrections staff — and an ability to “work the system” can be critical.

“People who genuinely have mental health issues, they did not receive much sympathy, I can tell you that,” said Johnny (not his real name), who has spent time in 10 NSW prisons over the past four years. “It’s a system; it’s just like any bureaucracy. I mean, obviously there are people who are good at dealing with people and perhaps get a bit of favouritism from the officers, or there are people who are not.

“If you have a mental health problem, you normally have problems just dealing with people, so … it’s unlikely that you can deal with the screws [custodial staff]. If you couldn’t deal with the screws, you wouldn’t get much favours in return, would you?”

Read ‘Mental health behind bars (part two): why women prisoners are set up to fail.’