LEVELS OF VIOLENCE AND MEDICATION IN A
SPECIAL PRISON UNIT, 1986-1995
Dr Bob Johnson, MRCPsych, MRCGP, PhD, MA, MBCS, DPM, MB, BChir, MRCS

INTRODUCTION:

Violent disruptive prisoners pose a sharp challenge to any prison system. Society locks violent citizens away, the prison service itself has fewer options. For, as one Home Secretary put it, "The mood and temper of the public with regard to the treatment of crime and criminals is one of the most unfailing tests of a country (being the) sign and proof of the living virtue in it". [Winston Churchill, Hansard, 1910.]

Violence is an increasingly serious social disease. Murder is already the commonest cause of death in women at work, and the second commonest for men in the U.S. [Dept of Labour Report,1994, Economist, Dec 3, 1994 P 67]. It is set to rise inexorably in the UK according to a recent monograph [Oliver James, "Violence Against the Person", Free Association Press, 1995.]. A great deal more is known about its origins than is generally supposed, as Oliver James [op.cit.] makes clear.

In England in the early 1980s an enlightened penal policy led to three Special Units being established, whose principal objectives was to remove especially disruptive prisoners from the general system, while obviating the need to condemn them to long periods of segregation or solitary confinement. The Special Unit at Parkhurst Prison was opened in December 1985, and provides the data presented here.

Barlinnie was a Special Unit established in Scotland in 1973. Professor David Cooke's analysis [Brit. J. Criminol. spring 1989;129-143] showed that the regime there reduced assaults from an expected 105 to 2. The Barlinnie Special Unit was closed in December 1994.

From July 1991 to the present, every prisoner in the Parkhust Special Unit who consented, was seen on a weekly basis by the consultant psychiatrist (currently all of them). The approach deployed was to pursue and attempt to disentangle the long-term effects of child abuse, essentially an extension of Post Traumatic Stress Disorder (PTSD), along similar lines to those pioneered by Alice Miller ["For Your Own Good", Virago, 1980.]

METHOD:

Research was regarded from the outset as an important component of these Special Units. Detailed records of inmates' ill-discipline were recorded on a monthly diary sheet. These form the basis for the data presented although "diary data" is inevitably incomplete and inaccurate. Actual physical injuries, either of inmate or staff, are significant enough to attract notice and ensure greater accuracy in recording.

Medication records are less complete. Only since late 1992 has the pharmacy kept dispensing data on computer. The 1990/91 figure is therefore an extrapolation from the prescribing patterns as recorded in June 1991; the 1992/93 data is based on the first 6 months of 1993; 1994 is an extrapolation of drugs dispensed to the end of January 1995. The 12 month periods run from July 1st in each year.

RESULTS:

The numbers of inmates in the Special Unit throughout this period did not vary widely, usually in the range of 14 to 16, with a maximum of 18; a total of 54 men passing through in 9 years. Currently there are 15, all lifers except one serving 16 years, and all for murder or attempted murder, except one for firearms offences.

The incidence of actual physical assault on another person is shown on table 1. Graph 1 groups this data into two year bands. Attacks on property are omitted.

DISCUSSION:

This data is interesting for two reasons in particular. Firstly though measurement of mental health is essentially subjective, happiness for instance being notoriously difficult to define, weighing the drugs dispensed in this relatively closed Special Unit (only four newcomers per annum on average) comes close to objectively measuring the subjective mental health of the inmates.

Secondly the conventional view that symptoms of violent disorders should be tackled by increasing medication has been stood on its head. Here a group of violent, unstable, ill-disciplined lifers have had their tranquillising medication consciously cut by 95%. This has not led to an increase in violence. A reduction of one assault per inmate per annum in 1986, to zero in 1994. should do more than encourage the team currently working on the Unit. A reduction of around 5 thousand pounds in sedative drug costs annually for 15 patients would, if applied nationally , represent savings of several million pounds.

It is clear that the staff on the Special Unit are now adept defusing violent incidents and for the most part containing them within the Unit. They provide an indispensable supportive ethos which alone permits the weekly psychiatric therapy sessions to function. Sensitive areas simply could not even be discussed, let alone explored without it.

Psychopaths are widely regarded as untreatable – and clearly they commonly are, when the treatment offered is either unfocussed psychodynamic counselling, or sedative medication. The fantasies, symbolisms and "free association" favoured by Freud have little relevance to the harsh realism of maximum security prisoners – indeed, on occasion they can be counter-productive.

What severe Personality Disorders require is a positive emotional involvement, together with a proactive approach in undoing the buried terror remaining from childhood trauma. This terror distorts thinking, and is therefore difficult to resolve unaided. It freezes the individual at the emotional age of five or thereabouts. By gently teasing out the implications, "value therapy" demonstrates that the original trauma is now over, and will not recur in adult life. Mature social strategies therefore become available, and violence is seen to be both socially maladaptive and emotionally immature. The target is to eliminate it altogether, an aim shared by all participating inmates, who now, for the most part co-operate with the Unit staff in reducing it.

Subjective clinical impressions are that most prisoners, once over their initial shock, warmly welcome the opportunity to disentangle their childhood traumas, in the safe, supportive atmosphere that this Special Unit currently provides. The results suggest the possibility of a method to reverse the rising tide of violence which besets society at large and prisons in particular.

Bob Johnson
February 13th, 1995
Orchard Hospital, Fairlee Road
Newport, Isle of Wight
PO30 2EP UK

Defendant Acquitted of Murder Due to Excessive
Prescriptive Doses of Valium
R V McGuire
The Law Society's Gazette, Wednesday (pp. 2177),
22nd July, 1987

The defendant was a 60-year-old Glaswegian housewife with no history of violent behaviour. In January 1979, after 30 years of marriage, her husband left her to live with another woman.

Consequently she complained of 'anxiety and tension'. Her GP prescribed diazepam (2mg twice daily) which she took for several months. However, as her symptoms subsided she reduced her intake, ceasing altogether by July 1979.

In January 1980 a summons for divorce was issued on her behalf which included a substantial financial claim.

In March 1980 her husband returned, following an apparent wish for reconciliation, but which was probably financially motivated.

The reconciliation was a complete failure as the husband continued to see the other woman and clearly intended to return to her.

By 25th March, the defendant was very agitated and distressed by events. She arranged to see her solicitor the next day with a view to proceeding with the divorce.

On the morning of 26th March, because of her continued anxiety, the defendant visited her GP. She did not see him personally, but his receptionist arranged for her to receive a prescription of 72 x 5mg diazepam tablets labelled: 'take when necessary'; the defendant had the prescription dispensed forthwith and took 5mg diazepam between 10.30 and 11.00am. As she was still very nervous, she took further doses at noon, 2.00, 3.45 and 5pm. She saw her solicitor at 4.30pm and went home.

At about 6pm the defendant was preparing supper, and using a sharp kitchen knife, when her husband came in. A fierce row developed. She apparently lunged at him [the husband], stabbing him to death, and then ran out of the house to her daughter's home. She explained what had happened and then promptly fell asleep on the sofa. The police were called and arrested the defendant at about 7.30pm.

After she had been taken into custody, the defendant took a further dose of diazepam at 9.00pm. A blood sample taken at 00.20am on 27th March showed a diazepam level of 0.5mg/l, and a nordiazepam level of 0.6mg/l. There was no alcohol present.

On 8th July, 1980, the defendant was charged with murder. At the trial, Professor Michael Rawlins said that he believed the tragedy was probably precipitated by the excessive amount (30mg) of diazepam which the defendant had consumed in the preceding twelve-hour period before her husband's death (she had eaten almost nothing during that time). In his view, the drug was responsible for the paradoxical aggressive outburst by the defendant who was not in full possession of her faculties at the relevant time.

She remembered experiencing subjective symptoms of 'muzziness' in her head and of her feet 'not touching the ground', which are typical responses to excessive diazepam dosage.

Professor Rawlins stated that paradoxical aggressive outbursts are a recognised adverse effect of diazepam; they are probably caused by the suppression of mechanisms which normally inhibit aggressive outbursts.

The judge directed the jury that the evidence would support a verdict of 'not proven'. However the jury acquitted the defendant completely, presumably on the basis that the defendant was not responsible for her acts owing to the effects of excessive diazepam.

Effect of Psychotropic Drugs in a Prison Setting –
A Federal Maximum Security Institution
Workman D.G., Cunningham D.G.
Canadian Family Physician, November 1975

Observations:

Violent aggressive incidents occurred in inmates who were on psychotropic drugs more frequently than in those who were not.

81% of the cases took diazepam (Valium).

3.6 times as many acts of aggression occurred when inmates were on these drugs.

For the other classes of psychotropic medication the aggressive incident rate was double the rate of those not no psychotropic medication.

Crimes committed by those inmates in the study included: murder, attempted rape, rape, attempted murder, indecent assault, assault, armed robbery, robbery with violence, assault or wounding with intent.

Period studied: 1st December 1972 – May 31st 1973 (6 months). All males, age range 18-50.

Of the 28 inmates who received some psychotropic medication, 22 showed a greater rate of aggressive incidents on days when on medication than days when off medication.

The group who did receive some medication were not significantly more aggressive as a group over the whole time period studied, but their acts of aggression were clearly tied to the taking of psychotropic drugs.

Of the total psychotropic medication used, 70% was prescribed by the prison psychiatrist. This seems to disprove any disclaimer that the aggressive incidents occurred because the inmate was anxious and unable to control his frustration, or would have been aggressive regardless of drug ingestion, since the inmate was better able to control his aggression before he received the psychotropic medication, whereupon the aggressive incident rate almost triples.

Considering that certainly not all aggressive personalities are in prison, that frustration also abounds in society and that diazepam is the most commonly prescribed drug in the U.S., with chlordiazepoxide (Librium) third. The implications of the combination of anti-anxiety agents and aggressiveness are astounding.

Further, considering the paucity of information concerning the effects of psychotropic medication on selected groups, or on the mechanisms of these drugs, more investigation seems mandatory.

Canadian Family Physician,
November 1975

At Risk Behaviour Associated With Clonazepam
Achieving Excellence in Health Care
Annual Report
Corrections Health Service
New South Wales 1995-96

Following representations by the Minister for Corrective Services on the basis of information from the Corrections Health Service and the Department of Corrective Services, the prescription of clonazepam under the Pharmaceutical Benefits Scheme now requires medical practitioners to obtain authorisation.

Clonazepam was responsible for a significant proportion of illicit intoxication and so disinhibited and emotionally reactive and aggressive behaviour by inmates in correctional centres with the consequence of "at risk" behaviour such as self harm and suicide attempts. Restricting the condition for prescribing clonazepam in the community is a most significant achievement in the reduction of "at risk" behaviour in correctional centres.

Prior to restriction, clonazepam was available in 200 tablet quantities contrasting 50 for other benzodiazepines and its tablet was a smaller size but some four times as potent as these other tablets. Now, to obtain these tablets on the Pharmaceutical Benefits Scheme, the person must have epilepsy which is not responsive to more traditional anticonvulsant drugs.

The Use of Benzodiazepines in Prison Populations
BROWN C.R.
Journal of Clinical Psychiatry 1978; 39: 219-222.

"Experiences at the Utah State Prison with the use of psychotropic medication... indicated that the indiscriminate use of benzodiazepines could lead to more detriment than benefit. (p. 220)

"During 1974 when several tranquillizers and pain killers were being used relatively indiscriminately... the incidence of riots, stabbings, cuttings, murders and attempted suicides and self-mutilations were extremely high. 22 cases of sputum injections, deliberate self-mutilations were reported during that period.

"In addition there were two major riots and five minor riots, one murder, two suicides, 44 self mutilations, 6 stabbings of other individuals, 8 attacks on guards, and innumerable verbal assaults on guards and other inmates. (p. 221)

"Several prisoners had acute withdrawal symptoms and some who were addicted to Valium and other benzodiazepines had a prolonged withdrawal effect, much longer than even the heroin and methadone addicts." (p. 221)