There is a high prevalence of people with mental illness and intellectual disabilities in Ireland’s prisons. The prevalence of severe mental illness is four times that of the general population and one in three people screen positive for an intellectual disability (Gulati et al. Reference Gulati, Keating, O’Neill, Delaunois, Meagher and Dunne2019; Gulati et al. Reference Gulati, Murphy, Clarke, Delcellier, Meagher, Kennedy and Dunne2018). This overrepresentation is equally manifested in contacts with An Garda Síochána, Ireland’s police force. A recent Garda Inspectorate review of custody risk assessments found that in a sample of 318 custody records, 24% noted “poor mental health or self-harm,” while 5% identified a “learning disability” (Garda Síochána Inspectorate, 2022). These are likely to be underestimates based on incomplete data.
It has been argued that addressing high prison prevalence of intellectual disabilities requires identification, safeguards, and considerations of alternatives to incarceration at the policing stage of the criminal justice pathway (Gulati et al. Reference Gulati, Cusack, Kilcommins and Dunne2020a). People with intellectual disabilities report finding policing interactions variously frightening, confusing, and describe difficulties in understanding and communicating information (Gulati et al. Reference Gulati, Cusack, Kelly, Kilcommins and Dunne2020b). Yet, the challenges in recognizing disability are acknowledged internationally (Young et al. Reference Young, Goodwin, Sedgwick and Gudjonsson2013; Gulati et al. Reference Gulati, Kelly, Cusack, Kilcommins and Dunne2020c; Gulati et al. Reference Gulati, Cusack, Bogue, O'Connor, Murphy, Whelan, Cullen, McGovern, Kelly, Fistein, Kilcommins and Dunne2021a). The ability of police in identifying intellectual disabilities can be assisted by training programs, which need not be onerous or resource-intensive (Reference Gulati, Cusack, Murphy, Kelly, Kilcommins and Dunne2021b). Yet, doctors have a key role to play in assisting Gardai (as the Irish police service is known generally) in identifying vulnerability, providing assessments of fitness to be interviewed and in the judicious application of mental health legislation where this is strictly necessary (Reference Gulati, Kelly, Cullen, Kukaswadia, Cusack, Kilcommins and Dunne2021c). Clarity around the remit of mental health legislation is particularly necessary in the overlap between mental illness and intoxication, particularly in a context where 48% of those attending Garda stations suffer with substance abuse/intoxication (Garda Síochána Inspectorate, 2022) and applications by Gardai remain the most frequent form of application for detention under the Mental Health Act 2001 (Mental Health Commission, 2021).
In contrast with England and Wales, where doctors attending police stations receive specialist training and qualifications to serve as forensic physicians (Sarkar and Stark, Reference Sarkar and Stark2010), there is a paucity of formal training opportunities for Irish General Practitioners (GPs) attending Garda stations in respect of intellectual disabilities and mental illness.
In addressing this lacuna, we designed a pilot training program for GPs with an interest in working at the Garda interface. The content of the program was similar to the strategy undertaken by our research group in designing training for Gardai, grounded in studies evaluating lived experience of people with disabilities (Gulati et al. Reference Gulati, Cusack, Kelly, Kilcommins and Dunne2020b) and focussing on an empirically developed approach based on recognition of intellectual disabilities, communication strategies, the provision of information, and an awareness of the need for supports (Gulati et al. Reference Gulati, Cusack, Murphy, Kelly, Kilcommins and Dunne2021b). This was augmented by learning objectives around the assessment of fitness to be interviewed by the police and relevance of the Mental Health Act 2001 in the setting of the Garda station. GP participants were recruited by open advertisement through the University of Limerick Education and Research Network for General Practice (ULEARN-GP) (O’Regan et al. Reference O'Regan, Hayes, O'Connor, Casey, O'Dwyer, Culhane, O'Donnell, Stack, Cuddihy, O'Connell, O'Flynn, Cullen, O'Doherty, O'Connell and Glynn2020), and CPD approval obtained from the Irish College of General Practitioners. Ethical approval was obtained for evaluation of effectiveness. All participation was voluntary. The training comprised a 90-minute interactive online seminar. Pre- and post-training Likert scales were used for evaluation of effectiveness.
Fourteen GPs completed the pre-training evaluation. Eleven GPs attended the training and seven of these completed the post-training evaluation. The results of the evaluation are outlined in Table 1. Perceptible benefits were reported by the participant group in confidence levels around identifying intellectual disabilities, communication strategies, knowledge around safeguards for people with intellectual disabilities, and crisis management. Perceptible increases were similarly reported in confidence levels around the assessment of fitness to be interviewed and the use of mental health legislation. However, study limitations included a relatively modest sample size and the possibility of selection bias. GPs with a special interest in forensic medical practice were more likely to enrol in this session and equally more likely to be confident in these skills at baseline given their clinical experience. Notwithstanding these limitations, the current study outlines potential evidence that a single training session grounded in the findings of those with lived experience can produce perceptible benefits in confidence levels amongst GPs in important areas of forensic primary care practice.
The right to medical assistance remains a key safeguard for a person detained in Garda custody (Garda Síochána Inspectorate, 2022), and medicine has a critical role to play in addressing the societal challenge where people with disabilities are overrepresented in the criminal justice system. As highlighted by the Council of Europe (2014), much needs to be done to strengthen this valuable safeguard, with training and resources for GPs operating in Garda stations. Psychiatrists have a valuable role to play, not just in collaborating clinically with primary care, but also in training and advocacy. The value of cross-disciplinary partnerships in this area cannot be overemphasised.
Conflict of interest
The authors have no conflicts of interest to disclose.
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was obtained from the University Hospital Limerick Research Ethics Committee.
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.