A Lesson From Switzerland: Mental Health Care and Corrections


During my summer trip to Geneva, I had the opportunity to visit Prison de Champ-Dollon, just northeast of the city center, and to meet with the clinical and forensic psychiatry staff there.

I learned a number of things that are humbling to me, and may be to the reader as well.

This “prison” is actually a jail, built to house about 340 detainees and short-stay inmates, but the current population hovers at 800.

Part of the reason for this is the inability of long-term prisons to accept newly sentenced inmates due to their own overcrowding. This may sound very familiar to readers in many parts of the U.S., and especially in California.

About 120 (15 percent) of the individuals housed at Champ-Dollon presently are on the mental health caseload. This should also ring true to readers in the U.S.

The visit made clear to me that the struggle for prison reform and better mental health services goes beyond our own borders.

As in the U.S., pretrial detention – and most criminal justice – is based in regional entities. In Switzerland they are called Cantons.

Thus, crimes, procedures and punishments may vary widely in different parts of Switzerland.

But unlike in the US, there is no overarching “federal” system. All criminal justice services are based in the Cantons. The Swiss federal court system becomes involved only when there are constitutional issues raised— and then only to adjudicate the constitutional issue at hand.

The prison health services at Champ-Dollon are provided in a partnership with Hôpitaux Universitaire de Genève. While my visit did not focus on the details of the relationship between the academic medical center and the jail itself, it was clear from discussions with my Swiss colleagues and my observations of their interactions with the custody staff at the jail that they are an integral part of the operation of the jail.

My visit included a tour of the medical and psychiatric clinic on the fourth floor of the jail itself, which (like most everything in Switzerland) was much cleaner than the jails to which I have (unfortunately) become accustomed.

Unlike in the U.S., I did not feel the need to wash my hands immediately upon leaving.

I also had the opportunity to visit the local psychiatric hospital, located in a lovely place with the lovely name “Belle-Idée.”

This is a 200 bed psychiatric hospital with specialized units for geriatric patients, people with developmental disabilities, people with addictions, and about 30 or 35 forensic patients.

The hospital has two units specifically utilized for people in the criminal justice system. One is a secured, seven-bed unit designed for crisis care for inmates and detainees in the jail who are acutely ill. Patients are stabilized fairly quickly (average stay is 8 days) and returned to the jail to continue with their pretrial procedures or their sentence.

This unit functions as an analog to civil commitment from a jail or prison in the US.

Another unit of approximately 25 beds serves as a kind of “halfway house.”

Patients are admitted here at the end of their sentences under a court mandate to remain pending further order of the court. Typical patients stay here 1-3 years, during which time they receive intensive multimodal therapy focusing on helping them (re)acclimate to life in the community as functioning citizens.

The unit is open, and the hospital staff rely on their relationships with the patients to maintain them safely on the unit during the period of the court order.

As in the jail, I found these units to be remarkably clean and orderly.

What is different? First, all citizens of Switzerland have health insurance permitting them to use all needed medical and mental health services. People who cannot afford to pay a premium do not pay, and they have access to all of the same services.

Second, unlike where I work, the psychiatric hospital in Geneva is not an extension of local jails.

While Switzerland (or at least the Canton of Geneva) suffers with jail and prison overcrowding, and while 15 percent of their inmates and detainees have mental health needs, the psychiatric hospital remains essentially a civil hospital with the exception of two small specialized units for forensic patients.

I suspect that the second difference has much to do with the first.

Erik Roskes, a regular blogger for The Crime Report, is a forensic psychiatrist and serves on the teaching faculty in the Psychiatry Department at the University of Maryland School of Medicine. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He welcomes readers' comments. Dr. Roskes' website is http://mysite.verizon.net/eroskes.

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