International Journal of Prisoner Health, September 2009; 5(3): 166170
ORIGINAL ARTICLE
Neglecting the mental health of prisoners
K. EDGAR1* & D. RICKFORD2 1
Head of Research, Prison Reform Trust, and 2Research Assistant, Prison Reform Trust
Abstract From first contact with the police to release from prison, people with mental ill health who come into conflict with the law often find that their mental health needs are neglected while they are under the authority of the criminal justice system. In 2008, the Prison Reform Trust surveyed independent monitoring boards in England and Wales, asking them to comment on mental health care. Topics included the adequacy of court diversion schemes, assessments carried out in prison reception units, and preparations to ensure continuity of care upon release. The responses documented some of the consequences of neglect in prisons in England and Wales. Over half of the boards felt that they frequently saw prisoners who were too ill to be in prison. Boards also expressed concerns about assessment processes in prison reception areas, which were by no means adequate to identify mental health problems. A number of boards stated that, too often, people with severe mental illnesses are held in segregation units, where they endure an impoverished regime. The boards observed that many prisons lack any means of identifying people who have learning disabilities, and often their disabilities restrict their capacity to engage fully with the regime.
Keywords: Mental health, diversion
The prison population in England and Wales, in February, 2009, was 82,596 (Ministry of Justice, 2009). The survey of psychiatric morbidity in the prison population by the Office for National Statistics (1998) found that 72% of male and 70% of female sentenced prisoners had two or more mental health problems; 7% of male sentenced prisoners, and 14% of female sentenced prisoners had a psychotic disorder (Singleton et al., 1998). The survey also found that 66% of prisoners had a personality disorder, as compared to 5.3% of the general population; 45% of prisoners had a neurotic illness (such as depression), as compared to 13.8% of the general population; and 8% of prisoners had an identified schizophrenia or delusional disorder, as compared to 0.5% of the general population. It has been estimated that approximately 3700 prisoners suffer from psychiatric problems so severe that they require urgent transfer to psychiatric care (Edgar & Rickford, 2005). Given that the ONS survey is over 10 years old, an independent review of the diversion of mentally ill people from the criminal justice system by Lord Bradley recommended that the Government should repeat the survey (Lord Bradley, 2009).
*Corresponding author. Email: [email protected] ISSN 1744-9200 print/ISSN 1744-9219 online # 2009 Taylor & Francis DOI: 10.1080/17449200903115839
International Journal of Prisoner Health
167
It is the responsibility of Prison Health, an agency in the Department of Health, to commission health care services including mental health care for prisoners. They do this primarily through mental health in-reach teams, which are intended to provide multidisciplinary specialist mental health care, specifically targeted at the most severely mentally ill prisoners (Brooker & Ullman, 2008). To investigate the extent to which the mental health care needs of prisoners were being met, the Prison Reform Trust conducted a survey of independent monitoring boards, through a partnership with the National Council for Independent Monitoring Boards. Independent monitoring boards are appointed by the Secretary of State for Justice to monitor fairness and respect for people in custody. As they are independent of the prisons, they provide a unique perspective on the treatment of prisoners and the conditions in prisons. The survey asked each board to comment on a range of aspects of mental health care, including the adequacy of court diversion schemes, assessments carried out in prison reception units, resources to provide mental health services, the needs of particular groups, and the preparations to ensure continuity of care upon release. Over one-third of the boards (57 out of 141) responded to the survey. The first topic was diversion. Court diversion schemes are intended to identify people who have severe mental illness early in the criminal justice process, so that they can be diverted to appropriate mental health care. The number of prisoners who have severe mental health problems indicates that these schemes are not functioning adequately. A survey of diversion schemes by Nacro found that staffing problems had prevented one-third of them from working properly (NACRO, 2005). A 2008 report on prison mental health care revealed that few of these schemes were performance managed, many areas in England and Wales had no scheme at all, and many relied on just one staff member (Brooker & Ullman, 2008). This under-resourcing by government is curious, because in 2002 the Home Office published evidence that diversion from the criminal justice system by a well-designed and funded diversion scheme results in both better clinical outcomes for the offender, and a significant reduction in the risk of re-offending. An evaluation by Dr David James and his colleagues found that the offenders who had been diverted at the court stage showed a 28% reconviction rate in two years, half that of the comparison group who were sent to prison (James et al., 2002). Of the 41 boards that made comments about diversion, over half felt that they frequently saw prisoners who were too ill to be in prison. The Bradley Report contains a number of recommendations intended to improve diversion services. Lord Bradley emphasises that the person’s mental health needs must be assessed early in the criminal justice process, ideally at the point of contact with the police (Lord Bradley, 2009). The boards also expressed concerns about assessment processes in prison reception areas, which were by no means adequate to identify mental health problems. The boards reported that many prisons lacked the resources to conduct full psychiatric assessments of those they receive, and problems cited by boards included: . a lack of information arriving with the person; . this means that too often prisons must rely on self-reports to build up a profile of the person’s needs; . too few prisons have access to specialist trained staff who can accurately assess mental health problems at an early stage.
168
K. Edgar & D. Rickford
These observations echo findings of other research. For example, a study conducted by the Sainsbury Centre for Mental Health found that assessments as the prisoner came through reception areas were cursory, often lasting no more than five minutes (Durcan, 2008). Moreover, the same study found that screening on reception was often the best chance anyone had of their mental health needs being recognised. In similar terms, a study by Policy Exchange quoted the Chief Inspector of Prisons, Anne Owers, who commented that concerns raised in reception interviews were often ignored: There’s a lot of tick box stuff, which is not followed up. The box that says ‘further information required’ was often not ticked, and many prisoners did not have a secondary health screen to fill out their medical history (Brooker & Ullman, 2008). Once in prison, many prisoners who have mental health problems find it difficult to cope with the environment. The boards who responded to the survey described the effects of prison life on distressed individuals. Their concerns echo the view expressed in a World Health Organisation guide to prison health care, which lists a lack of purposeful activity, enforced solitude, and a lack of privacy among the aspects of imprisonment that adversely affect mental health (WHO, 2007). A number of boards stated that, too often, people with severe mental illnesses end up on segregation units, because normal location is far too stressful. This means that they are subjected to an impoverished regime, as one board chair wrote: I have become increasingly concerned at the number of prisoners with mental health problems who are being moved from one Segregation Unit to another either because they are not suitable for normal location or because they refuse to locate anywhere except the ‘Block’. Another board suggested that disciplinary procedures were being used (inappropriately) to manage the behavioural problems of mentally ill prisoners: Too often we observe prisoners whose extreme, often bizarre, behaviour patterns present serious control problems within the prison. Such prisoners usually end up in the segregation unit, where their disruptive behaviour often continues. Many boards wrote about people who they felt should not have been sent to prison. For example, one described: . . . an 80-year-old confused man who also is unable to look after himself. We do not yet know whether he was known to social services but it seems likely. He has a five-year sentence for indecent exposure which is not surprising since he continually takes his clothes off. Another wrote about: . . . a vulnerable young man in his 20s who committed arson. He spent a long time, awaiting sentence, in a prison environment with which he was ill equipped to cope, frequently prone to self harm and to the influence of other prisoners, requiring considerable support from the prison staff.
International Journal of Prisoner Health
169
In theory, prisoners who are identified as seriously mentally ill should be promptly transferred to appropriate NHS care. Just over half of the boards stated that they were aware of serious delays in arranging for transfers. The transfer of prisoners to an outside mental health care establishment is only actioned when a prisoner has been ‘sectioned’. However, once ‘sectioned’, this does not necessarily mean a quick transfer as this depends on the availability of accommodation which is often at a premium. The psychiatrist will not ‘section’ anyone unless they know they have a date for a placement in an outside establishment. Boards also reported concerns about the number of prisoners who have learning disabilities and therefore face a more restrictive regime: Learning disabilities pose a great challenge to wing and other staff and mental health needs may not be detected in the general run of the prison. As board members we are not automatically informed of people with such needs. Many prisons lack any means of identifying people who have learning disabilities, and often their disabilities restrict their capacity to engage fully with the regime. The co-ordination required between services for substance misusers and mental health in-reach teams is often poor, with the consequence that people with dual diagnosis are often not provided with an integrated service. The survey also gathered evidence that the needs of particular groups were not receiving adequate attention. For example, even a short period of imprisonment can exacerbate a woman’s social circumstances. If abuse, self-harm, or depression is linked to her offending, it is very likely that her condition will worsen while she is inside. The Corston Report (2007) made a powerful case for a drastic reduction in the numbers of women sent to prison. While the Government has accepted 40 of 43 of Baroness Corston’s recommendations, implementation remains slow. Prisoners with mental health needs often face a combination of problems after release. They might need a tailored package of accommodation, drug misuse services, health care and support for physical and mental illness, and social services (Bowen et al., 2008). When vulnerable people are released from prison with no after-care arrangements in place, the predictable outcome is that the person is often returned to face a subsequent prison sentence. One in three of the boards responding believed that there was inadequate support from the community to provide continuity of mental health care. Remanded prisoners who were released directly from court were particularly likely to fall through the net. It appears that many people in this situation were released with no mental health plan, no support, and no links set up. On the basis of the survey findings, the Prison Reform Trust published a report which made a number of recommendations, among which are: A national network of court and police diversion and liaison schemes should be established, with performance targets and sustainable funding. Every prison should have specialist support in learning disabilities, providing a muchimproved assessment service and follow-up support for people with learning disabilities to enhance their quality of life in the prison.
170
K. Edgar & D. Rickford
Prison resettlement units and probation officers should alert Local Authorities of their duties to assess the needs of vulnerable prisoners at an early stage well before they are released from prison (Edgar & Rickford, 2009). From first contact with the police to release from prison, people with mental ill health who come into conflict with the law often find that their mental health needs are neglected while they are under the authority of the criminal justice system. The boards who responded to the Prison Reform Trust survey documented some of the consequences of neglect, which they observed in monitoring prisons in England and Wales. There are no simple solutions, but the boards’ evidence highlights some of the main obstacles to equivalence in mental health care for prisoners. One is that criminal justice systems inflict harms which they are poorly equipped to resolve, including social disadvantages such as a loss of housing, reduced chances of finding employment, or the destabilising impact on family relationships. A second problem is that the justice system holds primary responsibility for prisoners; managing prisoners’ needs is not easily shared with other social agencies, such as local authorities or health services. There are profound conflicts which get in the way of sharing the burden of caring for prisoners’ well-being. The underlying principle is that, while they are in prison, offenders remain citizens, with full rights to an equivalent standard of health care, and with other, (often unmet) rights to advice and support with housing, benefits, training, pensions, and family ties. The gains which could be achieved if this principle could be translated into practice should make improving the mental health care of offenders a public health priority. References Bowen, P., Markus, K., & Suterwalla, A. (2008). ‘Discharged prisoners’ rights to health care, housing and community care Part 1’ LAG, January 2008, 1822. Brooker, C., & Ullman, B. (2008). In Gavin Lockhart (Ed.), Out of sight, out of mind: The state of mental health care in prison (pp. 21ff). London: Policy Exchange. Corston, J. (2007). The Corston report: A review of women with particular vulnerabilities in the criminal justice system. London: The Home Office. Durcan, G. (2008). From the inside: Experiences of prison mental health care. London: Sainsbury Centre for Mental Health. Edgar, K., & Rickford, D. (2009). Too little, too late: An independent review of unmet mental health need in prison. London: Prison Reform Trust. Edgar, K., & Rickford, D. (2005). Troubled inside: The mental health needs of men in prison. London: Prison Reform Trust. James, D., Farnham, F., Moorey, H., Lloyd, H., Hill, K., Blizard, R., et al. (2002). Outcome of psychiatric admission through the courts, RDS Occasional Paper No. 79, London: The Home Office. Lord Bradley (2009). The Bradley report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system. London: Department of Health. Ministry of Justice (February, 2009). Prison population and accommodation briefing for 20th Feb, 2009. London: Ministry of Justice. Nacro (2005). Findings of the 2004 survey of court diversion/criminal justice mental health liaison schemes for mentally disordered offenders in England and Wales. London: Nacro. Singleton, N., Meltzer, H., Gatwald, R., Coid, J., & Deasy, D. (1998). Psychiatric morbidity among prisoners in England and Wales. London: Office for National Statistics. World Health Organisation (2007). In Lars Møller, H. Sto¨ver, R. Ju¨rgens, A. Gatherer, & H. Nikogosian (Eds.), Health in prisons: A WHO guide to the essentials in prison health (pp. 133145). Denmark: WHO Regional Office for Europe.
ORIGINAL ARTICLE
Neglecting the mental health of prisoners
K. EDGAR1* & D. RICKFORD2 1
Head of Research, Prison Reform Trust, and 2Research Assistant, Prison Reform Trust
Abstract From first contact with the police to release from prison, people with mental ill health who come into conflict with the law often find that their mental health needs are neglected while they are under the authority of the criminal justice system. In 2008, the Prison Reform Trust surveyed independent monitoring boards in England and Wales, asking them to comment on mental health care. Topics included the adequacy of court diversion schemes, assessments carried out in prison reception units, and preparations to ensure continuity of care upon release. The responses documented some of the consequences of neglect in prisons in England and Wales. Over half of the boards felt that they frequently saw prisoners who were too ill to be in prison. Boards also expressed concerns about assessment processes in prison reception areas, which were by no means adequate to identify mental health problems. A number of boards stated that, too often, people with severe mental illnesses are held in segregation units, where they endure an impoverished regime. The boards observed that many prisons lack any means of identifying people who have learning disabilities, and often their disabilities restrict their capacity to engage fully with the regime.
Keywords: Mental health, diversion
The prison population in England and Wales, in February, 2009, was 82,596 (Ministry of Justice, 2009). The survey of psychiatric morbidity in the prison population by the Office for National Statistics (1998) found that 72% of male and 70% of female sentenced prisoners had two or more mental health problems; 7% of male sentenced prisoners, and 14% of female sentenced prisoners had a psychotic disorder (Singleton et al., 1998). The survey also found that 66% of prisoners had a personality disorder, as compared to 5.3% of the general population; 45% of prisoners had a neurotic illness (such as depression), as compared to 13.8% of the general population; and 8% of prisoners had an identified schizophrenia or delusional disorder, as compared to 0.5% of the general population. It has been estimated that approximately 3700 prisoners suffer from psychiatric problems so severe that they require urgent transfer to psychiatric care (Edgar & Rickford, 2005). Given that the ONS survey is over 10 years old, an independent review of the diversion of mentally ill people from the criminal justice system by Lord Bradley recommended that the Government should repeat the survey (Lord Bradley, 2009).
*Corresponding author. Email: [email protected] ISSN 1744-9200 print/ISSN 1744-9219 online # 2009 Taylor & Francis DOI: 10.1080/17449200903115839
International Journal of Prisoner Health
167
It is the responsibility of Prison Health, an agency in the Department of Health, to commission health care services including mental health care for prisoners. They do this primarily through mental health in-reach teams, which are intended to provide multidisciplinary specialist mental health care, specifically targeted at the most severely mentally ill prisoners (Brooker & Ullman, 2008). To investigate the extent to which the mental health care needs of prisoners were being met, the Prison Reform Trust conducted a survey of independent monitoring boards, through a partnership with the National Council for Independent Monitoring Boards. Independent monitoring boards are appointed by the Secretary of State for Justice to monitor fairness and respect for people in custody. As they are independent of the prisons, they provide a unique perspective on the treatment of prisoners and the conditions in prisons. The survey asked each board to comment on a range of aspects of mental health care, including the adequacy of court diversion schemes, assessments carried out in prison reception units, resources to provide mental health services, the needs of particular groups, and the preparations to ensure continuity of care upon release. Over one-third of the boards (57 out of 141) responded to the survey. The first topic was diversion. Court diversion schemes are intended to identify people who have severe mental illness early in the criminal justice process, so that they can be diverted to appropriate mental health care. The number of prisoners who have severe mental health problems indicates that these schemes are not functioning adequately. A survey of diversion schemes by Nacro found that staffing problems had prevented one-third of them from working properly (NACRO, 2005). A 2008 report on prison mental health care revealed that few of these schemes were performance managed, many areas in England and Wales had no scheme at all, and many relied on just one staff member (Brooker & Ullman, 2008). This under-resourcing by government is curious, because in 2002 the Home Office published evidence that diversion from the criminal justice system by a well-designed and funded diversion scheme results in both better clinical outcomes for the offender, and a significant reduction in the risk of re-offending. An evaluation by Dr David James and his colleagues found that the offenders who had been diverted at the court stage showed a 28% reconviction rate in two years, half that of the comparison group who were sent to prison (James et al., 2002). Of the 41 boards that made comments about diversion, over half felt that they frequently saw prisoners who were too ill to be in prison. The Bradley Report contains a number of recommendations intended to improve diversion services. Lord Bradley emphasises that the person’s mental health needs must be assessed early in the criminal justice process, ideally at the point of contact with the police (Lord Bradley, 2009). The boards also expressed concerns about assessment processes in prison reception areas, which were by no means adequate to identify mental health problems. The boards reported that many prisons lacked the resources to conduct full psychiatric assessments of those they receive, and problems cited by boards included: . a lack of information arriving with the person; . this means that too often prisons must rely on self-reports to build up a profile of the person’s needs; . too few prisons have access to specialist trained staff who can accurately assess mental health problems at an early stage.
168
K. Edgar & D. Rickford
These observations echo findings of other research. For example, a study conducted by the Sainsbury Centre for Mental Health found that assessments as the prisoner came through reception areas were cursory, often lasting no more than five minutes (Durcan, 2008). Moreover, the same study found that screening on reception was often the best chance anyone had of their mental health needs being recognised. In similar terms, a study by Policy Exchange quoted the Chief Inspector of Prisons, Anne Owers, who commented that concerns raised in reception interviews were often ignored: There’s a lot of tick box stuff, which is not followed up. The box that says ‘further information required’ was often not ticked, and many prisoners did not have a secondary health screen to fill out their medical history (Brooker & Ullman, 2008). Once in prison, many prisoners who have mental health problems find it difficult to cope with the environment. The boards who responded to the survey described the effects of prison life on distressed individuals. Their concerns echo the view expressed in a World Health Organisation guide to prison health care, which lists a lack of purposeful activity, enforced solitude, and a lack of privacy among the aspects of imprisonment that adversely affect mental health (WHO, 2007). A number of boards stated that, too often, people with severe mental illnesses end up on segregation units, because normal location is far too stressful. This means that they are subjected to an impoverished regime, as one board chair wrote: I have become increasingly concerned at the number of prisoners with mental health problems who are being moved from one Segregation Unit to another either because they are not suitable for normal location or because they refuse to locate anywhere except the ‘Block’. Another board suggested that disciplinary procedures were being used (inappropriately) to manage the behavioural problems of mentally ill prisoners: Too often we observe prisoners whose extreme, often bizarre, behaviour patterns present serious control problems within the prison. Such prisoners usually end up in the segregation unit, where their disruptive behaviour often continues. Many boards wrote about people who they felt should not have been sent to prison. For example, one described: . . . an 80-year-old confused man who also is unable to look after himself. We do not yet know whether he was known to social services but it seems likely. He has a five-year sentence for indecent exposure which is not surprising since he continually takes his clothes off. Another wrote about: . . . a vulnerable young man in his 20s who committed arson. He spent a long time, awaiting sentence, in a prison environment with which he was ill equipped to cope, frequently prone to self harm and to the influence of other prisoners, requiring considerable support from the prison staff.
International Journal of Prisoner Health
169
In theory, prisoners who are identified as seriously mentally ill should be promptly transferred to appropriate NHS care. Just over half of the boards stated that they were aware of serious delays in arranging for transfers. The transfer of prisoners to an outside mental health care establishment is only actioned when a prisoner has been ‘sectioned’. However, once ‘sectioned’, this does not necessarily mean a quick transfer as this depends on the availability of accommodation which is often at a premium. The psychiatrist will not ‘section’ anyone unless they know they have a date for a placement in an outside establishment. Boards also reported concerns about the number of prisoners who have learning disabilities and therefore face a more restrictive regime: Learning disabilities pose a great challenge to wing and other staff and mental health needs may not be detected in the general run of the prison. As board members we are not automatically informed of people with such needs. Many prisons lack any means of identifying people who have learning disabilities, and often their disabilities restrict their capacity to engage fully with the regime. The co-ordination required between services for substance misusers and mental health in-reach teams is often poor, with the consequence that people with dual diagnosis are often not provided with an integrated service. The survey also gathered evidence that the needs of particular groups were not receiving adequate attention. For example, even a short period of imprisonment can exacerbate a woman’s social circumstances. If abuse, self-harm, or depression is linked to her offending, it is very likely that her condition will worsen while she is inside. The Corston Report (2007) made a powerful case for a drastic reduction in the numbers of women sent to prison. While the Government has accepted 40 of 43 of Baroness Corston’s recommendations, implementation remains slow. Prisoners with mental health needs often face a combination of problems after release. They might need a tailored package of accommodation, drug misuse services, health care and support for physical and mental illness, and social services (Bowen et al., 2008). When vulnerable people are released from prison with no after-care arrangements in place, the predictable outcome is that the person is often returned to face a subsequent prison sentence. One in three of the boards responding believed that there was inadequate support from the community to provide continuity of mental health care. Remanded prisoners who were released directly from court were particularly likely to fall through the net. It appears that many people in this situation were released with no mental health plan, no support, and no links set up. On the basis of the survey findings, the Prison Reform Trust published a report which made a number of recommendations, among which are: A national network of court and police diversion and liaison schemes should be established, with performance targets and sustainable funding. Every prison should have specialist support in learning disabilities, providing a muchimproved assessment service and follow-up support for people with learning disabilities to enhance their quality of life in the prison.
170
K. Edgar & D. Rickford
Prison resettlement units and probation officers should alert Local Authorities of their duties to assess the needs of vulnerable prisoners at an early stage well before they are released from prison (Edgar & Rickford, 2009). From first contact with the police to release from prison, people with mental ill health who come into conflict with the law often find that their mental health needs are neglected while they are under the authority of the criminal justice system. The boards who responded to the Prison Reform Trust survey documented some of the consequences of neglect, which they observed in monitoring prisons in England and Wales. There are no simple solutions, but the boards’ evidence highlights some of the main obstacles to equivalence in mental health care for prisoners. One is that criminal justice systems inflict harms which they are poorly equipped to resolve, including social disadvantages such as a loss of housing, reduced chances of finding employment, or the destabilising impact on family relationships. A second problem is that the justice system holds primary responsibility for prisoners; managing prisoners’ needs is not easily shared with other social agencies, such as local authorities or health services. There are profound conflicts which get in the way of sharing the burden of caring for prisoners’ well-being. The underlying principle is that, while they are in prison, offenders remain citizens, with full rights to an equivalent standard of health care, and with other, (often unmet) rights to advice and support with housing, benefits, training, pensions, and family ties. The gains which could be achieved if this principle could be translated into practice should make improving the mental health care of offenders a public health priority. References Bowen, P., Markus, K., & Suterwalla, A. (2008). ‘Discharged prisoners’ rights to health care, housing and community care Part 1’ LAG, January 2008, 1822. Brooker, C., & Ullman, B. (2008). In Gavin Lockhart (Ed.), Out of sight, out of mind: The state of mental health care in prison (pp. 21ff). London: Policy Exchange. Corston, J. (2007). The Corston report: A review of women with particular vulnerabilities in the criminal justice system. London: The Home Office. Durcan, G. (2008). From the inside: Experiences of prison mental health care. London: Sainsbury Centre for Mental Health. Edgar, K., & Rickford, D. (2009). Too little, too late: An independent review of unmet mental health need in prison. London: Prison Reform Trust. Edgar, K., & Rickford, D. (2005). Troubled inside: The mental health needs of men in prison. London: Prison Reform Trust. James, D., Farnham, F., Moorey, H., Lloyd, H., Hill, K., Blizard, R., et al. (2002). Outcome of psychiatric admission through the courts, RDS Occasional Paper No. 79, London: The Home Office. Lord Bradley (2009). The Bradley report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system. London: Department of Health. Ministry of Justice (February, 2009). Prison population and accommodation briefing for 20th Feb, 2009. London: Ministry of Justice. Nacro (2005). Findings of the 2004 survey of court diversion/criminal justice mental health liaison schemes for mentally disordered offenders in England and Wales. London: Nacro. Singleton, N., Meltzer, H., Gatwald, R., Coid, J., & Deasy, D. (1998). Psychiatric morbidity among prisoners in England and Wales. London: Office for National Statistics. World Health Organisation (2007). In Lars Møller, H. Sto¨ver, R. Ju¨rgens, A. Gatherer, & H. Nikogosian (Eds.), Health in prisons: A WHO guide to the essentials in prison health (pp. 133145). Denmark: WHO Regional Office for Europe.
