Ever since I heard Priti Patel’s draconian comment that she wants criminals to “literally feel terror” at the thought of breaking the law back in August, I have felt compelled to do something about it. In this case, I’ve taken to writing. As a prison GP myself, that ominous phrase not only sickens me to this day, it shocks me. Lumping all prisoners together in a homogenous group and wishing fear on them is heartless. And, given that for many, terror will already have been a part of their formative years outside of prison, it was ignorant too.
Two weeks ago at work, I received a telephone from a nurse.
“Can you suture, doctor ?”
“Will you suture someone’s cut? Then he doesn’t need to go out to A&E.”
“I will. Where’s the cut?”
“Oh, he’s tried to cut his nipple off; he’s done it before.”
The man, diagnosed with borderline personality disorder (BPD), was brought over from the prison wing. His body bore signs of severe, repeated self-harm.
We had some time to talk while the nurse gathered together the items needed for suturing. I asked if he had ever been seen by a psychologist: “A psychiatrist? I’ve seen a psychiatrist.”
“No, a psychologist.”
“I’ve never heard of a psychologist.”
BPD is a complex psycho-social disorder. The characteristics emerge in adolescence or early adult life. Although the cause of BPD is likely to be multifactorial, many people diagnosed with the condition report physical, sexual or emotional abuse, or neglect, in childhood. Children being terriﬁed.
Unstable mood, unpredictable outbursts of anger, poor self-image, fear of abandonment, self-harm and suicide attempts are some of the long-term features of BPD that affect a person’s ability to function in society. Thrill-seeking and impulsive behaviour without consideration of the consequences increases the risk of criminal activity. The incidence of drug use is high among people with BPD.
In England and Wales, the estimated prevalence of BPD is 23 per cent among male remand prisoners, 14 per cent among sentenced male prisoners and 20 per cent among female prisoners. Many of these will be abused children who have grown up; traumatised in childhood, their needs unmet.
I try to imagine what these people could be subjected to following arrest under Patel’s plans for policing. Will this terror-inducing treatment be at the time of arrest or in police custody? Will it occur in prison on remand or perhaps later following sentencing? Treatment sanctioned by a government that creates terror in detained individuals makes me think of torture.
The man whose wound I sutured had been the subject of abuse in childhood. Would being dealt with in custody in a manner that caused him to feel terror be a deterrent to reoffending? No. People with BPD are impulsive and volatile; their criminal action more likely to be unplanned. Such treatment would be cruel and almost definitely trigger and intensify the features of BPD that had perhaps resulted in the crime in the ﬁrst place.
Currently, when the expressed aim of the government is not to induce terror in prisoners but support them to reform, is there hope of treatment and rehabilitation for my patient?
The treatment required is psychotherapy delivered by a highly qualiﬁed professional, usually a clinical psychologist. Despite the high incidence of BPD in prisons, my experience leads me to assess that the availability of treatment is woefully inadequate.
There was no BPD psychotherapy provision in any of the five prisons that I’ve worked in since 2015. One of the reasons given by a provider for the lack of provision was that a psychotherapy service had not been commissioned by NHS England. The same provider pointed out that therapy is needed over many months and its completion is not possible if short sentences are being served. (This does not explain the lack of provision for those serving long sentences.) A persistent cycle of prison-community-prison does not enable engagement with therapeutic services in either place.
There are prisons with specialist personality disorder units. There are a few Pipes (Psychologically Informed Planned Environments). However, my day-to-day experience as a GP is that most people with the condition have not been offered psychotherapy or do not have access to it.
I don’t want to continue to feel unresourced when faced with another person with a self-harm wound to suture. I feel complicit in their suffering.
I am ashamed that our country has a home secretary that chooses to use that horriﬁc phrase. And, as we’ve seen following the launch of the Tory manifesto, the party will clearly stick to its historical treatment of offenders in the name of keeping our “streets safer”, with promises of 10,000 new prison places. As Francis Crook, chief executive of the Howard League for Penal Reform, said in response to the Conservative Party’s 2017 manifesto: “It is a pity there is no mention of shrinking the [prison] population as the welcome promise to prepare people for employment will evaporate in stinking, violent, drug-addled, self-cutting, assault-ridden and crowded prisons.”
Justice for the victims of crime and safety for society, yes. Terror for all criminals, no. I’d like to ask her to research, understand and address the personal and societal factors that traumatise individuals, increase their risk of BPD and increase the risk of their future criminal activity.
I’d encourage her to create well-staffed, generously resourced prisons where treatment, reform and rehabilitation is the aim. I’d like her to give the adults who were the abused children some hope that though they were neglected then, they will be supported and treated now.
If you’ve experienced any of the issues mentioned in this article and would like to talk to someone about it, you can contact charity Samaritans by calling 116 123 or emailing firstname.lastname@example.org