‘Most have to put up a wall to get some sense of safety’

When I first started seeing residents in prison I was struck by the courage and resilience they showed. I wanted to understand the source of their suffering, to connect with it, to hold a space for their recovery. One resident explained that he was burdened by flashbacks and nightmares about the war he had witnessed and experienced. Other residents told me stories of their struggles to find safety… those they trusted would soon turn on them and before they knew it, they were involved in criminal, drug or gang affiliation. I realised then how our human needs to find a sense of belonging could drive us to live the life of crime, prison and punishment. Trauma can have a severe impact on the lives of those who are vulnerable in society. Their stories captivated me. 

I had applied to be an Assistant Psychologist in the prison establishment because I was curious about what trauma informed care could look like in this setting. The prison system is often not conducive to rehabilitation: could this type of approach really work? As I walked the corridor of healthcare I had seen professionals hurriedly going about their work, lots of conversations about medication. What were they medicating, who were they medicating? It felt oppressive to me, and my curiosity was piqued. I sat with the psychologist, my supervisor. I began to learn about Compassion Focused Therapy and the opportunities this approach can open up. 

Providing the tools

I introduced the Three Systems Model of Emotion in Compassion Focused Therapy by Paul Gilbert to help residents understand the impact of trauma on their mind and body. This offered a simple explanation to what happens to people after traumatic life experiences. They began to gain an understanding of why they experienced flashbacks and nightmares, and this helped to normalise their experiences. They were able to identify and understand their triggers and what kept their threat system activated. I would spent time helping them build their 'soothing system' by introducing grounding techniques and stabilisation, helping residents develop mindful awareness. Slowly they were able to take a step back from their overwhelming feelings and thoughts to become observers of their experiences. One resident found safety statements particularly helpful: this reminded him that what happened was in the past and that helped him to focus his attention on the present. Steadily residents were able to build up the skills and resilience to manage their flashbacks and nightmares; and reported that they felt more in control of them. 

My supervisor had spoken to the team about some of the unintended consequences of trauma informed care, the unhelpfulness of taking long histories of past traumatic experiences – this can be destabilising for people. During my work with one particular resident, I learnt first-hand of the importance of keeping sessions contained, delivering psychoeducation to help people understand why they experience what they do and provide them with tools so that they know what to do. 

Just as this resident was becoming more curious about the mind-body links to trauma, he was transferred to another establishment, without any notice. I was unable to have an ending session with him. This felt difficult, but it was reassuring to know that our work had been containing and safe.

A triggering place

I have learnt that a collaborative formulation can help to provide a shared understanding of difficulties. Some residents can have quite a fixed mindset and I find this group a little harder to engage. However, when they start to learn that their thoughts, behaviours and feelings are responses to potential past difficulties, they become more interested in learning what they can do to help themselves. For some residents, engaging in this process helps them to recognise why they might have avoided doing so before. The medical model of care has a strong presence in the prison – it is a challenge to develop and deliver trauma informed care in this setting. Frequently, behaviour is identified as problematic and offered symptom relief through the use of medication. This can then be seen as the solution to long-term difficulties. 

I have learned that the prison environment can act as a catalyst for residents to ruminate on their traumatic life experiences, revealing painful thoughts and feelings. In prison, there are not many things for residents to do, and the pandemic has seen an increase in restrictions, which compound their lived experience. The residents are locked up for 22 hours a day, and this makes it really difficult for residents to create a sense of safeness. Being in confined spaces for prolonged periods can evoke anxiety and paranoia. I worked with another resident who showed me how the prison environment can be a triggering place: his problem did not affect his everyday life when he was in the community.

I often find myself reassuring residents that their feelings are a valid response to their situation. I engage in active listening to ensure that they feel heard and understood. Together we start the process of thinking about what they might find helpful. From my experience, there are times when the CFT approach is not suitable; for instance when one is not ready to engage in any type of work, and this could be due to a number of things. A theme that comes up repeatedly in my sessions is holding on to the narrative of pain and suffering because it feels safer and more contained than getting to know a new version of 'me' away from crime, forgiveness and acceptance. This involves a lot of work. Often, working on their problems can be so daunting and overwhelming that most of the time, they'd rather self-medicate or manage on their own. I have also come across residents who do seek mental health support, but their drug use acts as a barrier for engaging with any type of work. 

The prison is a strange environment and one that affects people in different ways. I learned to work effectively in this environment you have to be good with your boundaries, at all levels. Otherwise, it can quickly become an unsafe environment for everyone.  

A chance to heal

As an AP, my role involves delivering stabilisation in the form of helping residents develop skills to be able to self-regulate and psycho-education. I am also involved in the assessment process, which I then discuss in our team meeting. Working in this environment, supervision is hugely important. It helps me feel safe and contained. For cases that are complex, I either work jointly with the team's psychologist or with another senior member of staff. There are times when the need of a resident isn't talking therapy, but more on medication management. Then they are allocated to our mental health prescribers, or appointments are arranged with the psychiatrist. I also create resources for the residents. This has involved self-help guides tailored for the environment, and creating a mini-series of animated videos for residents offering psychoeducation using principles of CFT and ways of navigating and coping with lockdown, during prolonged period in their cells. 

For the residents it's a small prison with clear instructions and routine provided for them; in contrast it can feel like I have unlimited options and endless possibilities, which brings its own challenges. I've learned that sometimes it is not about the residents' issues… the system around them can be difficult to navigate, adding another layer of complexity. As a society it is easy to project the dark side of humanity onto these individuals, who have committed horrible crimes. But the environment remains unsafe for most of them, and they are often re-traumatised by the system. Most have to put up a wall in order to get some sense of safety. We need to give them a chance to heal from their traumas. 

Learning about Compassion Focused Therapy and the work of Paul Gilbert has changed my outlook, allowing me to lean in to suffering instead of turning away. I see and learn to understand the common aspects of humanity. When working with residents I often emphasised the words of Paul Gilbert; 'It is not our fault, but it is our responsibility to recognise things that contributed to our suffering'. It is only then we can start to heal. I see it as our responsibility to help these individuals, focus on caring, listen to their story instead of just their crimes, and stop shaming these individuals… after all, we've all got the dark side. 

Look for the silver lining

As for my own career progression, my experiences so far have involved working in clinical and forensic settings and have enjoyed both. I am considering applying to the Forensic and Clinical Doctorate with Birmingham University; I feel that this course complements my existing skills and experiences. The course offers the flexibility to work in both settings when qualified. I can see the value of having both specialities, especially in the prison and secure settings, where both mental health and criminogenic risk and needs are important. 

My role in the prison has given me valuable experience towards my career, but also for my personal growth. Prison being one of the most difficult places I've worked in. It is hard to sit with things you have no control over, aspects of the system you don't feel are right. I learned to look for the silver lining. When an opportunity to help arises, take a chance and grab it… it might be that appointment which will make a difference this time around. Be open, curious and humble, meeting people from all walks of life. Hear their stories and wisdom.  

-       Cellyn P has been working as an Assistant Psychologist for two years, after gaining experience in settings such as neurorehabilitation and secure hospitals.

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