Finland's Prison Healthcare: A House of Contradictions

Medscape

a day ago

On May 7, Finland's deputy parliamentary ombudsman issued a statement criticizing 'shortcomings in the availability of and access to psychiatric care for prisoners.' According to the statement, current service levels do not satisfy prisoners' legal rights, highlighting a curious discrepancy: Although Finland's prison healthcare system is purported to be among the best in the world, its prisoners still have exceptionally high rates of psychiatric disorders, psychoses, and even suicide.
Finland's penal system, like those of other Nordic countries, focuses not on punishment but on rehabilitation and integration as a productive member of society. According to Finnish law, imprisonment should only involve a loss or restriction of liberty without impeding the prisoner's other rights unless necessary. Prisoners have a legal right to education, social services, and healthcare. Nevertheless, the Wattu IV National Study on the Health and Wellbeing of Prisoners, published in 2023, reported that about 88% of the prison population has a personality disorder. Roughly 8% of prisoners suffer from some form of psychosis compared with about 2% of the general Finnish population. The study also reported lower rates of trust and higher rates of social isolation among the prison population.
Mika Rautanen, MD
'What's a little bit surprising is that, when we compare with the Nordics or other countries, our numbers are higher,' said Mika Rautanen, MD, department head at the Health Care Services for Prisoners (VTH), who led the study. 'It's interesting, and I'm not sure why that's so.'
Universal Care
Rautanen's puzzlement reflects the mismatch between Finland's extensive prison healthcare system and its lackluster results. Finland is one of a handful of countries in which prison healthcare falls under the purview of the Ministry of Health rather than the Ministry of Justice. VTH is part of the Finnish Institute for Health and Welfare, which provides healthcare services to the general population.
'We take a holistic approach to people in prisons. Many different factors are entangled together in their problems, so we have to consider the whole person in order to help them,' Rautanen told Medscape Medical News . 'Not every country has a special healthcare service dedicated to prisoners. We have our own hospitals, as well as health clinics with doctors and nurses inside the prison walls,' he said.
VTH operates Finland's psychiatric hospital for prisoners, which also provides outpatient services to prisons. Rautanen explained that prisoners can easily get a referral. Nurses are required to give prisoners a checkup when they are admitted to prison and at other times during their imprisonment. The prison staff can also contact the hospital services and ask for help when they are concerned about an individual.
Pia Puolakka, MPsych
The Prison and Probation Service (RISE) also provides rehabilitative support to prisoners, though they distinguish it from mental health care. While it may include cognitive-behavioral therapy and psychological work, 'rehabilitation is a wider concept than mental health care,' explained Pia Puolakka, MPsych, a senior specialist and team leader at RISE, speaking with Medscape Medical News . Mental health services deal with conditions like depression, anxiety, or other mental health disorders, she said, while rehabilitation focuses on behavioral management strategies and reducing the risk for recidivism, partly through study and work programs.
Prisoners Have Many Mental Health Problems
Despite these services, prisoners in Finland carry a significant mental health burden.
To some extent, this may be a reflection of Finland's very small prison population. A campaign starting in the 1960s brought the prisoner rate down from about 200 per 100,000 to a relatively low 50-60, in line with the other Nordic countries. This was accomplished by changes in sentencing and legislation, particularly for theft and drunken driving: Shorter sentences, expanded parole, an increase in the use of conditional sentences, and a shift to noncustodial sentences, such as fines and community service.
The higher mental health burden in the prison population might therefore be because it is a distinct subpopulation. A 2023 study found that psychiatric hospitalization rates in Finnish municipalities correlate with violent crime rates. The author also found that providing supportive housing for people with serious mental illnesses and visits with mental health care professionals could have crime-reducing impacts.
Another explanation of the high rates of mental health issues in Finnish prisons could be that Finland has collected exceptionally good data, said Rautanen. The Wattu IV prisoner health and well-being study wasn't just a questionnaire or survey, he explained; the researchers had the resources to visit the prisoners, interview them, and evaluate the situation. In other words, the high rates may simply capture the true situation, and lower rates in reports from other countries might result from less thorough data collection.
In support of this idea, Rautanen pointed out that the psychosis rate in the 2023 Wattu IV report was about the same as in the previous study published in 2010. 'It's alarming that we haven't been able to reduce it — we have to do something — but I think the fact that it's similar suggests that the numbers really are right,' he said.
High Suicide Rates
However, differences in another statistic are more difficult to explain as being based on better data collection: The suicide rate. A 2017 study in The Lancet Psychiatry reported that the Nordic countries had the highest prison suicide rates out of the 24 rich countries surveyed. Within the prison population, Nordics had suicide rates of 91-180 per 100,000. Finland had 103 per 100,000. The suicide rate in Finnish prisons was 4.8 times higher than in the general population; in Norway, it was 14 times higher. In Belgium, Spain, and New Zealand, the suicide rate in prison was also about five times higher than in the general population (4.7-5.5), while the US, Croatia, Canada, and Poland had far lower ratios (0.7-2.3).
The study also found a negative correlation between incarceration rate and suicide rate. For example, Canada had an incarceration rate of 141 per 100,000 (compared with Finland's 56) and a prison suicide rate of 27 per 100,000. The authors speculated that smaller prison populations likely consist of people who have committed serious or violent crimes or have high rates of mental illness, increasing the risk for suicide. By contrast, high incarceration rates make the prison population more similar to the general population, effectively diluting the high-risk groups into a mixed population.
While this explanation may partially account for the difference in suicide rates, it also presents an implicit challenge to the Nordic penal model. The Nordic penal system is considered exceptionally humane and is often held up as an example for other countries, but its suicide statistics are similar to those in western and southern European countries — both in terms of the prison suicide rate and its comparison with the general population's suicide rate. How is the Nordic model falling short?
'There's no simple answer to that,' said Puolakka. 'When people say that Nordic prisons are exceptional, I always say that we have a very good system that provides services and healthcare, but even if a prison is made of gold, it's still a prison,' she continued. 'People who haven't been imprisoned probably don't understand it; being imprisoned is a crisis and a traumatic life experience.'
Access to Care
Puolakka's point is reflected in VTH data. About 32% of prisoners said they have tried to harm themselves or attempted suicide, and roughly 25% reported a life satisfaction score of ≤ 4 (out of 10), with 4% scoring their life satisfaction at 0.
'We should check up more,' said Rautanen, explaining that the current arrangement requires nurses or staff to spot prisoners in need or prisoners to ask for help themselves. 'We should go there and try to find the people who need us.'
…even if a prison is made of gold, it's still a prison…being imprisoned is a crisis and a traumatic life experience.
According to Rautanen, many prisoners might not trust the health services enough to approach them, or they may not recognize that they have a mental health condition. He pointed out that prisoners who frequently contact the mental health services may not have severe issues, while those with psychosis, paranoia, or other antisocial traits 'can be very hidden, and we don't hear about them.'
Miisa Törölä, PhD, a criminology researcher at the University of Helsinki, Helsinki, Finland, commented on the same problem. 'Healthcare staff don't necessarily visit the prison wards, even if they have their unit right there,' she told Medscape Medical News . She explained that prisoners can request help via a written complaint, which puts the burden on them. 'I think they don't necessarily recognize their symptoms or see that there's anything wrong with their behavior. Making it [the prisoners'] duty to be very active in getting help is problematic.'
Miisa Törölä, PhD
In at least some cases, prisoners want care but cannot access it.
Alexander Vahera-Chibnik worked as a prison guard in Helsinki for several months in 2020 and 2021. He described a case where a prisoner took extreme measures to get mental health care. 'About an hour after being booked into the prison, they attempted to hang themselves with their bedsheet,' he recalled, speaking with Medscape Medical News . Vahera-Chibnik was the first on the scene, and after the prisoner was saved, he was tasked with escorting them to the prison psychiatric hospital. The prisoner had previously been imprisoned in Oulu, Northern Finland. 'They told me that while in prison at Oulu, they had attempted to access care due to depression, suicidal thoughts, and drug addiction but been repeatedly denied,' Vahera-Chibnik said. 'In their words, they felt that their only way forward was to either take their own life or survive the attempt and get access to care that way.'
Alexander Vahera-Chibnik
The morning after the incident, Vahera-Chibnik overheard one of the criminal sanctions officers say, 'They should have just let that fucking addict hang.' Vahera-Chibnik said this reflects the extremely negative attitude that prison guards can have toward inmates with drug addiction.
'The fact that someone with that mindset was able to be promoted in the system and that that's something, which can be comfortably said aloud in a crowded locker room speaks to the general attitude of the prison guards,' he said.
In another case, Vahera-Chibnik called the prison nurse when he found an inmate 'engaged in some strange behavior, like standing at the stove and passing their hand over the burners and talking to themselves.' He said the nurse observed briefly and then told him to call again if the prisoner hurt themselves or someone else. 'I would not be surprised at all if denying care is a common practice,' he said.
Gaps in the System
The overall shortcomings of the prison mental health care system are affirmed by the deputy parliamentary ombudsman's reprimand. The statement charged VTH with investigating and correcting any ambiguities in referral practices in prisons and requested that the Ministry of Social Affairs and Health and the Ministry of Justice investigate how the mental health care of prisoners can be improved.
Törölä said that the problem is at least partly structural. 'You have to have a chronic, severe mental illness to be remanded to the forensic psychiatric unit. The prison psychiatric hospital gives treatment for acute situations. There's a gap in between,' she said. Prisoners who need longer-term therapy and support fall through this gap in the system.
Another issue is balancing different needs. 'My understanding is that mental health care isn't necessarily prioritized in prison because there are other things to take care of before that, like cutting off substance abuse,' she said. These problems can be especially pronounced with prisoners who are serving a short sentence, which might not provide enough time for rehabilitation.
Prison Minorities
Another structural problem is who the Finnish prison system focuses on.
Helena Huhta, PhD, a sociologist and criminologist at the University of Turku, Turku, Finland, pointed out that even though 18% of the prison population are not Finnish, the Wattu health and well-being study only involved Finnish prisoners. 'This reflects the general approach to foreign prisoners in the Finnish prison system,' she told Medscape Medical News . 'We know next to nothing about the mental health of foreign prisoners or how the prison services meet their mental health needs. There are no studies about that.'
Helena Huhta, PhD
Rautanen acknowledged that shortcoming, adding that other groups are also missing, such as very short-term prisoners and prisoners in the more remote northern and eastern parts of the country. He explained that this was due to not having enough resources to cover tens of languages and travel to all distant prisons. 'Next, we should conduct focused smaller studies,' he said.
Huhta also raised the question of ethnic minorities in Finnish prisons, noting that there are about 200 Roma imprisoned in Finland. 'That's quite a strong overrepresentation, and it would be a really important topic to research,' she said.
RISE is 'very aware of the ethnic and other minority groups,' Puolakka said, adding that there are specific practices intended for them. For example, there are women-specific programs, and the prison service also collaborates with NGOs that are specialized in the needs of Roma people.
'One important thing that defines how much you can benefit from services in Finnish prisons is how well you know the Finnish language and Finnish culture,' said Puolakka, adding that whether a person will stay in Finland or be deported after imprisonment is also a major factor determining their needs during imprisonment.
While RISE may recognize these needs, Huhta said they often aren't met. She said that during prison visits for her PhD research a decade ago, she observed that a lack of Finnish language skills and an ethnic hierarchy among the prisoners limited their access to work and schooling opportunities. She recalled being told by a prison staff member leading a workshop that he wasn't going to accept anyone on his team who belonged to an ethnic minority. She added that prison guards sometimes refuse to speak English with prisoners, and translated forms are not systematically used, creating unnecessary hurdles for foreign prisoners. In addition, she said that Muslim prisoners are often denied access to an imam, while Christian prisoners have regular access to a priest.
Many of the 18% of prisoners who are not Finnish face deportation after their release. 'That's often a much graver consequence of crime than imprisonment,' said Huhta, since it completely uproots someone from their life. 'All prisoners should receive preparation for their release — help finding housing or arranging needed services after release, for example — but prisoners who will be deported are often denied that because the officers think they can't do it since they don't know the society the person will be deported to.'
Huhta explained that the deportation process itself is unclear to most of the prisoners, and some of them will be deported to a country they left as a child, with which they have little or no actual connection. 'It's really stressful for many prisoners. They would benefit a lot from having someone to discuss the process with, as well as how they could use their existing skills, resources, and connections to build a new life,' she said. 'Having the possibility to reflect on these things with someone before getting released would be very important.'
Contradictions That Are Not Unique
The Nordic penal model, generally considered exceptionally humane, proves to house contradictions, with prison suicide rates similar to other European countries and high mental health burdens among the prison population. These discrepancies are not unique to Finland. For example, doctoral researcher Pernille Nyvoll of the University of Oslo, Oslo, Norway, has written about how 'the unsolvable conflict between care and control in prison' shapes prisoners' healthcare experience in Norway's prisons.
To explain these contradictions, Huhta referenced a 2013 paper by Vanessa Barker of Stockholm University, Stockholm, Sweden, which calls the Nordic penal system 'Janus-faced,' saying that 'it is mild and harsh simultaneously.' Barker wrote that this mirrors the dual nature of Nordic welfare states, which combine democratic egalitarianism with an ethno-cultural idea of citizenship. She argued that this dynamic needs to be understood when evaluating the Nordic penal system, which is often held up as a model worth emulating without fully understanding its exclusionary mechanisms and limitations. While the Nordic model has many admirable elements, its shortcomings must also be recognized and analyzed.