My name is Janne Hermansen, and I am a psychiatrist in Norway with broad clinical and leadership experience. I have practical and supervisor training in cognitive behavioral therapy and metacognitive therapy, and I have completed university degree in radicalization and violent extremism. I am currently a clinical director at Ringerike District Psychiatric Centre (i.e., Ringerike Distriktspsykiatriske Senter; DPS). I have worked with Ringerike prison in Honefoss for six years, focusing on the assessment and treatment of severely mentally ill patients with a high risk of violence. I am currently leading a new mental health care program at Ringerike Prison, and in this article I will describe the content, purpose, and preliminary outcomes of the project.
The program is designed as a four-year project, consisting of an initial 12-month pilot phase followed by a three-year main phase. The pilot year focuses on establishing collaboration structures, clarifying roles and responsibilities across services, testing working methods, and defining a clear target group and model of care. The subsequent three years are intended for full implementation, further development, and systematic evaluation of the model in practice. This includes sustained clinical follow-up of inmates with severe mental illness, refinement of individualized and flexible treatment pathways inspired by Flexible Assertive Community Treatment (FACT) principles, strengthening transitions between prison, hospital care, and community services. Over time, the project aims to generate knowledge about feasibility, outcomes, and transfer value, with the ambition that the model can inform future service development in other prisons.
Healthcare import model in Norwegian prison system
The Norwegian model of healthcare in prisons is based on the principle of imported services. The import model means that health services in prisons are part of the public healthcare system. They are not organizationally subordinate to the correctional services. Healthcare professionals therefore work on the same professional and legal basis as outside of prison. They have clear professional independence and a clear responsibility for treatment toward the patient, even when the patient is deprived of liberty.
A fundamental principle in Norwegian prisons is the principle of normality. The deprivation of liberty itself constitutes the punishment, while other rights should be maintained as far as possible. For health services, this means that inmates have the same right to necessary healthcare as the rest of the population. Municipalities are responsible for primary healthcare services in prison. The specialist mental health services provide more advanced treatment. This organization helps ensure continuity of care before, during, and after imprisonment.
The Norwegian model places particular emphasis on equality, patient rights, and professional independence. For healthcare professionals working in Norwegian prisons, this involves a clear understanding of their role. Their loyalty lies with the patient and the health profession. At the same time, their work takes place in close cooperation with the correctional services, within the framework of security and daily operations.
Ringerike Prison
Ringerike Prison is a high-security prison with a total capacity of 160 cells. All inmates are housed in single cells. It is possible to double-occupy some cells, but this has not been done in recent years. The prison is organized into several units with different security levels and services.
- Unit A is a restrictive housing unit where conditions of imprisonment vary. Some inmates have limited contact with others, while others are completely isolated from other inmates. This depends on individual security assessments and individual circumstances.
- Units B, C, and D are general population units. Unit B has a woodworking workshop where inmates can take part in work related to wood processing. Unit C has a mechanical workshop with similar work opportunities in mechanical trades. Unit D is mainly linked to education and schooling. It offers upper secondary education and some vocational training. This includes subjects such as carpentry and cooking.
- The prison also has a unit for particularly high security, kat a so-called “supermax” level, with two inmates. This unit is intended for inmates with special security challenges. It has a very strict regime regarding control, movement, and contact. Inmates in this unit are assessed as needing exceptionally high security. For example, some domestic terrorists are held at this security level. Nationwide, only four inmates are housed at this level.
Specialist mental health services via DPS have psychologists and a psychiatrist working inside the prison. Their tasks include acute risk assessments, evaluations, and treatment through therapy and medication. Follow-up of inmates receiving treatment from DPS is conducted in the same way as ordinary outpatient follow-up outside prison. Inmates who need higher level of care are transferred out of the prison and admitted to a hospital psychiatric ward.
Challenges
Mental health care in prison is largely organized as ordinary outpatient follow-up. This model can work well for inmates who are stable, motivated, and able to attend and benefit from scheduled consultations. However, a significant proportion of inmates with severe mental illness do not fit this format. Many have fluctuating functioning, limited insight, or symptoms such as psychosis, anxiety, or paranoia that make it difficult to engage meaningfully in office-based conversations. In practice, treatment may be reduced to irregular attendance, brief assessments, and documentation of missed appointments, rather than providing the continuous and adaptive care that is actually needed.
For many of these inmates, the primary need is not only conversation, but structured and coordinated support in everyday life. This includes assistance with routines, activity and social interaction, as well as close observation over time. Such milieu-therapeutic interventions require consistency and coordination among those who interact with the inmate daily. In the prison context, however, the environment is primarily designed for security and operations, not for treatment. As a result, therapeutic follow-up often stands isolated from the rest of the day, while large amounts of time are spent in the cell without meaningful activity or support.
In severe cases, this can contribute to increased confinement, whether as a security response to challenging behavior or as withdrawal by the inmate. While confinement may reduce acute risk in the short term, it often exacerbates symptoms. It also limits opportunities for observation in natural situations, weakens therapeutic alliance, and delays recognition of deterioration until symptoms become acute.
The prison environment also presents interpersonal and safety-related challenges. Inmates with severe mental illness may display behavior that creates fear, irritation, or conflict in housing units, increasing the risk of threats, violence, exploitation, or social exclusion. Measures taken to protect others may further restrict the individual, reinforcing a cycle of reduced functioning and increased symptom pressure. At the same time, staff must balance security considerations with the inmate’s treatment needs.
Assessment and observation prior to possible hospital admission represent another challenge. Qualified clinical observation over time is often necessary to assess psychosis, suicide risk, severe mood disorders, or functional decline. In prison, such observation may easily be translated into increased control rather than health-related assessment. When healthcare professionals are not present around the clock, information becomes fragmented, and decisions about admission may be delayed or based on incomplete data.
Transitions between levels of care are particularly vulnerable. Inmates returning from psychiatric hospitalization, often with compulsory medication, require close follow-up to monitor effects, side effects, adherence, motivation, and risk. Prison conditions can make this difficult, and experiences of coercion may further weaken trust and engagement. Similarly, transitions at release are high-risk periods. If planning starts late or coordination with community services is weak, there is a substantial risk of treatment interruption, relapse, substance use, violence, or self-harm.
Finally, a central structural challenge is that prison officers are not healthcare professionals. Although they may be highly experienced in observing behavior, mental health symptoms are easily interpreted through a security-oriented lens. Subtle signs of relapse, affective instability, suicidality, or medication side effects may be misunderstood or overlooked. When healthcare professionals have limited contact with inmates, they become highly dependent on the quality of observation and communication from others, making coordinated and systematic collaboration essential.
A Holistic Approach
The purpose of a more individualized form of follow-up, inspired by a FACT approach, is to adapt services to the individual’s level of functioning and risk. It also aims to reduce dependence on the patient’s ability to attend and benefit from traditional consultations. Such an approach seeks to shift the focus from office-based conversations to follow-up that takes place where problems arise, in everyday life, in the environment, and during transitions. It is based on the idea that some patients need frequent, brief contacts, flexible intensity, close coordination, and a combination of mental health care, substance use treatment, somatic care, and practical support, rather than a single treatment modality.
A FACT team is a multidisciplinary, outreach-based treatment model for individuals with severe mental illness. The core is a team that shares responsibility for a defined group of patients and can rapidly adjust the intensity of follow-up. When a patient is stable, follow-up can be more ordinary and planned. When the condition worsens, the team can quickly increase contact frequency, risk assessments, and coordinated efforts without waiting for new referrals or decisions. The team typically combines psychiatric assessment and medication follow-up, psychological treatment, substance use treatment, and practical rehabilitation support. Continuity is central, as the same team follows the patient over time and takes responsibility during critical phases.
Applied to a prison context, a FACT-like individualization is less about copying the model in full and more about adopting its principles. These include clear team responsibility, flexible intensity, more frequent low-threshold contacts for those who need it, more systematic support for environment and functioning, and better bridging to services outside prison before release. For inmates who cannot benefit from traditional outpatient conversations, this can mean that help becomes more practical and less vulnerable to missed appointments. For those who need observation, it can mean faster and more qualified assessments based on multiple data points from everyday life. For those returning after hospital admission with compulsory medication, it can mean closer follow-up of effects, side effects, motivation, and risk during a period when relapse is common. At release, such an approach can increase the likelihood of a seamless transition by ensuring early planning, secured appointments and medication, and active links to relevant teams and services in the community.
Overall, the point is that an outpatient model can be too limited for the most vulnerable inmates. Their needs often concern functioning, safety, structure, and continuous risk management as much as conversation itself. A more individualized, flexible, and team-based approach can reduce the gap between needs and services. It can provide more support in everyday life, detect deterioration earlier, and make the transition out of prison less abrupt.
Application for collaborative funding
To address the complex challenges related to follow-up of inmates with severe mental illness, I applied for collaborative funding with a clear ambition to strengthen cooperation between primary services, specialist health services, and the correctional services. The purpose of the project is to develop a more coordinated, holistic, and flexible form of follow-up. The aim is for the different actors to work closely together around each individual inmate, rather than in parallel within separate systems. The starting point for the application was the recognition that many of these challenges cannot be solved by a single service alone. They require shared understanding, joint assessments, and coordinated practice.
The application process involved thorough anchoring in the clinic’s leadership, both professionally and organizationally. Emphasis was placed on ensuring that the initiative would be realistic within existing frameworks, while still representing a clear step forward in development. The application itself was extensive and detailed. It described the current challenges clearly, including lack of continuity between services, limitations of outpatient follow-up in prison, and vulnerable transitions between levels and systems. At the same time, the project was framed as more than a local issue. We described the need as national in scope. Many prisons face similar challenges, and a key premise has therefore been that the model developed should be transferable and adaptable to other prisons and regions.
The project is planned with a broad, multidisciplinary composition of expertise. This includes a psychiatrist and a psychologist for assessment, diagnosis, treatment, and risk evaluation. It also includes psychiatric nursing for close clinical follow-up and support in the daily environment, as well as social work competence to address social conditions, rights, coordination with municipal services, and release planning. User involvement is a central part of the project. This includes cooperation with WayBack, a local user organization that works with reintegration after imprisonment and offers support from people with lived experience of prison and substance use. Their contribution provides an important experience-based perspective and helps ensure that the measures are developed in line with real needs, both during imprisonment and in the transition to life after release.
An important element of the project is continuous evaluation of the services provided. We have planned systematic evaluation throughout the process. This allows for adjustment of direction, identification of what works and what should be changed, and documentation of effects and learning points. This is essential both for quality assurance and for assessing further implementation and transfer value to other prisons. The project was granted funding for a 12-month pilot phase, followed by a three-year main project. The pilot phase provides time to establish cooperation, clarify roles, test working methods, and develop a shared understanding among the actors involved. The main project then allows for longer-term testing, further development, and evaluation of the model. The overall goal is to contribute to better and more coherent services for a particularly vulnerable group of inmates.
Next steps
The way forward will initially have a clear focus on establishing stable frameworks for collaboration during the pilot phase. This includes fixed and structured meeting points between primary healthcare services, specialist mental health services, and the correctional services. The purpose is to build shared understanding, trust, and commitment. These meetings will be used both for overall planning and for discussing concrete experiences and challenges that arise along the way, so that the project develops in close interaction with clinical practice.
A central part of the work in this phase will be systematic documentation. Clear collaboration agreements, routines, and clarifications of responsibility will be developed. These will specify who does what, when, and on what basis. Particularly important is the work on developing a shared and correct practice for confidentiality, information sharing, and medical records. This requires thorough clarification across sector boundaries. Healthcare professionals must be able to fulfil their documentation and treatment responsibilities, while the framework of the correctional services is respected. Clear guidance in this area is essential to avoid uncertainty in practice and to safeguard both patient rights and legal security.
The pilot phase will also be used to further define the model itself. This includes clearly defining the target group, clarifying which needs the service should primarily address, and how the intensity and content of follow-up can be individually adapted. It will also be necessary to develop routines for handling deterioration, crises, and transitions. This includes cooperation during hospital admission, return to prison, and planning for release. An important goal is to reduce vulnerability during transition phases and to ensure better continuity of care.
Once the framework is sufficiently clarified, the next phase will be recruitment. This includes advertising positions, conducting interviews, and selecting candidates with relevant professional competence and experience. At the same time, emphasis will be placed on the ability to work flexibly and across disciplines within a complex system. Staff will need to understand both healthcare perspectives and the specific conditions of the prison context. In parallel, training and a shared introduction to the project’s goals, working methods, and values will be planned.
In addition, a structure for evaluation will be established at an early stage. This includes clarifying how experiences will be documented, which indicators will be followed, and how feedback from both staff and service users can be actively used in further development. Evaluation is not seen as a final activity, but as an ongoing tool for adjustment and quality assurance.
Overall, the way forward is about building a solid foundation before full implementation. The pilot phase will ensure that collaboration is well anchored, that the framework is clear, and that the model is realistic, professionally sound, and transferable. This will provide the basis for a main project that can offer more holistic and targeted follow-up for inmates with extensive mental health challenges.
Dr Janne Hermansen | Clinical Director | Ringerike District Psychiatric Centre
Questions? Contact Janne.g.hermansen@gmail.com
