A different model of care for people with mental disorders in prisons
The model of psychiatric care in prisons in Catalonia is considered the most advanced in Europe. Reaching this point has not been easy, but the results achieved undoubtedly justify the efforts. To understand the present and design a future with options, it is essential to learn from the past. Knowing history is the way to do so.
Therefore, we will focus on some noteworthy moments.
The journey to the current situation has two key socio-political moments: the first, in 1981, when the health powers (health and social centers and services) were transferred to Catalonia and the second, in 1984, when the powers in penitentiary matters were transferred.
Mental health in the prison ecosystem
Catalonia, in accordance with its Statute of Autonomy, has jurisdiction over prison administration. This jurisdiction entails managing and organizing all aspects of prison policy, personnel, and facilities in accordance with Spanish law, except for certain offenses such as terrorism or organized crime. The transfer of this jurisdiction took effect on January 1, 1984, by virtue of Royal Decree 3482/1983, of December 28.
The legislation applicable to the prison system is the same throughout Spain and comprises the Spanish Constitution of 1978, the General Organic Law on Prisons of 1979, the Penal Code of 1995, and the Prison Regulations of 1996. Although the legal basis is the same throughout Spain, in practice there are two political and administrative systems with jurisdiction over the organization and management of the prison system: the Spanish State Prison Administration and the Catalan Prison Administration. The Department of Justice of the Government of Catalonia (Generalitat de Catalunya) has exclusive authority over prison administration policy in Catalonia through the Secretariat of Prison Services, Rehabilitation, and Juvenile Justice.
In 1991, an agreement was signed between the Department of Health and the Department of Justice to guarantee adequate healthcare for people incarcerated in prisons.
In 2001, an agreement between the Department of Health, the Department of Justice, and the Hospitaller Order of Saint John of God established the plan of needs in the field of prison mental health. This agreement was drafted by a commission of mental health experts at the proposal of the Department of Health and the Department of Justice.
Until then, the model for addressing mental health needs within prisons in Catalonia was similar to that of the rest of Spain, with the existence of so-called "psychiatric infirmaries"—that is, architectural structures functionally more akin to residential modules than healthcare units. Furthermore, the healthcare staff who worked in these infirmaries belonged to the Department of Justice.
The signing of the agreement marks two historic milestones:
The deployment of a series of health-related structures as an alternative to infirmaries.
This translates into two basic actions:
- The Multipurpose Unit of the Quatre Camins Penitentiary Centre was launched in 2001
- Inauguration in 2003 of the Penitentiary Psychiatric Hospitalization Unit of Catalonia (UHPP-C), located in the Brians Penitentiary Center 1
The staff who will attend to mental health within the prisons will become part of a health entity , in this case Sant Joan de Déu, which is the largest provider of mental health services in the province of Barcelona.
The opening of the UHPP was a major health milestone of this agreement, as it is a 100% health clinical management unit, with emergency, acute, subacute, medium stay, and community transition services, legally classified as a mixed hospital, and of a suprasectoral nature, so it serves the entire prison population of Catalonia, which is in a closed regime.
In 2006, Decree 399/2006, of October 24, was published, assigning the Department of Health the functions related to the health and healthcare of incarcerated individuals. The current healthcare system within prisons is part of the public healthcare network of the Catalan Health Service (Servei Català de Salut). The primary prison healthcare provider is the Catalan Health Institute (Institut Català de la Salut), and specialized mental health care providers are managed by contracted entities in each territory. In the province of Barcelona, this is the Mental Health Network of the Sant Joan de Déu Health Park , which also manages the inpatient units for the entire prison population of Catalonia.
From this point forward, progress was made towards the development of a prison mental health network in Catalonia. In 2007, the Brians 2 Penitentiary Center opened, and in 2009, the Intensive Psychiatric Hospitalization and Rehabilitation Unit of Catalonia (UHRPI-C) was inaugurated within this center. This unit, which operates across different sectors, initially had 22 beds. Subsequently, throughout 2018, its deployment was completed, expanding to a total of 80 beds for inmates undergoing rehabilitation and transition to the community, whether serving a psychiatric confinement order or a prison sentence.
In 2017, the Catalan administration established the need to improve mental health care in the penal field, developing from the Department of Health and the Department of Justice, a series of actions with the aim of establishing a portfolio of mental health care services that completes a rehabilitative, community, comprehensive and equitable approach.
In this regard, high-impact actions and programs are being carried out:
- Barcelona's Modelo prison is closed, and mental health care for the pretrial detention population is transferred to the UHPP-C in Brians 1.
- The UHRPI-C in Brians 2 is being expanded from 22 to 80 places.
- The Quatre Camins infirmary is temporarily closed for its conversion into a health unit.
- The Outpatient Mental Health Care Service (SAASM) is being implemented in Catalan prisons, following the model established in the region and known as the Collaborative Program with Primary Care. This service has a strong community focus. Each prison has a SAASM team that reports to the local mental health service provider.
- The Individualized Support Program (PSI) in the prison setting is implemented, aimed at inpatients who have a severe mental disorder and are in a semi-freedom regime, whether in an open center, open section or dependent unit.
Currently, the reopening of the Quatre Camins rehabilitation unit is pending, which completes the offer of mental health care, dependent and managed by the Department of Health, operating in a network with a clear community vocation, highly specialized, with professionals specializing in mental health.
A recovery-based care model
The paradigm that underpins all interventions is the recovery paradigm . The concept of recovery refers to strengthening one's own capabilities and developing new skills focused on improving quality of life. It equips individuals with tools that facilitate the development of their own life project, according to their possibilities, expectations, and values. This is done even if symptoms persist, with the goal of regaining active control over their own lives.
Recovery, social integration and support upon leaving the prison
This paradigm represents a novelty in the care of people with mental disorders in prisons in Catalonia and comes to cover a deficit that existed in the care of mental disorders, adding a plus of quality, and facilitating community reintegration, by working to maintain the community links of the patient with his family and his environment.
The key steps taken, and the essence of the model, can be graphically represented in the following image.
There is still a way to go, but without a doubt, the care provided to mental health conditions within the prisons of Catalonia is now a humanized approach to the individual, as it should be.