New Voices: Breaking free - prisoners and mental health

'It was a terrifying experience... sometimes I didn't eat and I was losing weight, and my mind was just everywhere. I couldn't think straight.'

With the media awash with stories of prison being too soft and providing a 'cushy' lifestyle for inmates, it is important to remember the harsh realities of life inside, as captured above by the words of a former inmate, 'Femi', describing his experience on All in the Mind on Radio 4. Research indicates that over 90 per cent of prisoners have at least one type of mental health problem (Singleton et al., 1998), with more than 70 per cent having a diagnosis of two or more mental health disorders (Office of the Deputy Prime Minister, 2004). It is not clear whether these high statistics are due to disorders being present before admission to prison and then exacerbated by the stress of incarceration, or whether mental disorders develop as a result of the conditions prisoners are kept in. Either way, with the prison population having a number of risk factors for developing more serious mental health problems (Casswell et al., 2012), this suggests a clear need for early detection and intervention services within prisons.

Yet despite government policy promoting equivalence of care in prisons, prison mental health care has not seen the advancement in preventive services that has been seen in the community over recent years (Brooker et al., 2007), with the available services being mainly for those with severe and enduring mental illness.

Service provision may be needed when mental health problems emerge or are exacerbated by the prison environment.  For example, being isolated from support networks, bullying by other inmates, limited opportunity to engage in meaningful activity and uncertainty about the future could all impact negatively on a prisoner's mental health.

Recently proposed changes to prison policy could potentially have further negative implications, with the reforms proposed by the Ministry of Justice focusing largely on the first two weeks in prison. Possible changes include inmates being required to wear a uniform, having limited access to private cash (thereby further limiting calls to their support networks in the community) and having restricted access to television. The rationale for these reforms is that prisoners should enter into basic conditions, subsequently earning their privileges. Evidence suggests however that the first two weeks of imprisonment is a vulnerable time for prisoners where there can be an increased risk of suicide and self-harm. A third of prison suicides have been found to occur within the first week of imprisonment and 11 per cent take place within the first 24 hours (Shaw et al., 2004). Of these self-inflicted deaths, 72 per cent were known to have at least one psychiatric diagnosis.

Coming into prison is a stressful experience in itself, and those prisoners who are already struggling with mental health difficulties could deteriorate under the harsher conditions proposed. This makes the need for early detection and treatment of mental health problems more pressing than ever. 

Psychosis

Arguably a key area for early detection services to focus on is psychosis, with research suggesting substantially higher prevalence rates among prisoners than the general population. One study (Brugha et al., 2005) compared samples from the general population with prisoners and found the prevalence of psychosis was over 10 times greater in the prison group (5.2 per cent versus 0.4 per cent).

Research published on the care available for prisoners experiencing psychosis makes for depressing reading, with prisoners on inpatient wings spending an average of 21 hours a day locked up with limited interventions available (Reed & Lyne, 2000). An added complexity is that prisoners cannot be treated under the Mental Health Act as prison is not defined as a hospital by the Act, meaning treatment cannot be legally enforced (it only provides enforced treatment of mental disorder in a hospital). Prisoners who therefore require treatment but are unable or refuse to consent would need to be transferred to an NHS service in order for them to receive treatment. These transfers often entail lengthy delays, with 80 per cent of prison-to-hospital transfers taking over a month (Forrester et al., 2009). These delays are likely to impact negatively on those prisoners with psychosis since longer duration of untreated psychosis has been linked to worse outcomes (Barnes et al., 2008; Marshall et al., 2005).

In the community, services for the early detection of psychosis aim to reduce the amount of untreated psychosis, and there has been a move towards identifying and treating individuals with an 'at risk mental state' (ARMS). These individuals may have a genetic risk, be experiencing some sub-threshold psychotic symptoms or have experienced a brief period of psychotic symptoms in the past year (Yung et al., 2005). The aim of treatment is to prevent transition to psychosis or reduce the duration of untreated psychosis (Yung et al., 2007). Given the higher prevalence of prisoners with psychosis and some of the difficulties associated with providing adequate treatment in prison, there seems to be a clear need for early detection and intervention services within prisons.

OASIS in Prison

I have been fortunate enough to be part of the recently formed OASIS in Prison team. This clinical service for prisoners at risk of developing psychosis grew out of a study by Jarrett et al. (2012) which found that during initial screening, 5 per cent of prisoners met criteria for ARMS and a further 3 per cent had recently developed a first episode of psychosis. Based on these findings OASIS in Prison aims to identify prisoners with ARMS and provide a client-led intervention package consisting of both social and practical support and psychological therapy.

A unique aspect of the service is the capacity to offer support to prisoners both in prison and on their release, with the same clinician. This ensures a continuity of care that is not normally provided by prison services. Developing a therapeutic relationship in prison helps facilitate engagement with the service on release and feedback from prisoners who have accessed OASIS in Prison have commented that it is beneficial to work with someone who understands and has prior knowledge of the difficulties faced in prison and the challenges that may be awaiting them on release.

Working therapeutically within a prison environment raises its own unique array of challenges. Physical constraints such as lack of space, lack of privacy and restrictive prison regimes can all work against engagement with services. Treatment can be complicated by uncertainty around the length of sentences and disrupted by transfers to other prisons. With approximately 50 per cent of prisoners having a reading age of less than 11 years (Office of the Deputy Prime Minister, 2002), it is necessary to make adaptations to therapy. For example using visual formulations or diagrams to help individuals understand their difficulties visually or adapting language used in sessions to aid comprehension. Furthermore with most prisoners sharing cells and the subsequent lack of privacy, homework tasks and handouts, which often form an integral part of therapy, may not always be feasible. Although this creates challenges, it paves the way for a more creative approach to help prisoners retain and practise techniques covered in sessions, such as increased frequency of sessions and recapping of previous skills learnt.

A further common challenge in prison is the stigma around mental illness. This is widespread in the prison population and epitomised by comments that abound on the prison wings such as 'Miss, are you the one who works with the nutters?' It is often hard to hide the fact that someone is being seen by the mental health team, and prisoners may struggle with others being aware of this. Prisoners who are more open about their mental health difficulties face possible discrimination and marginalisation as a result, and thus there is understandably trepidation around the consequences of talking to a professional.

Harvey & Smedley (2010) detail how prisons are already low-trust environments and when many prisoners bring with them past experiences of abuse, this may impact on their ability to form relationships and place trust in others. Suspiciousness around confidentiality may also impact on the willingness of a prisoner to place their trust in a professional.

Despite these potential barriers, I have been surprised by the high level of engagement achieved by the OASIS in Prison service, with the vast majority of prisoners welcoming the opportunity to receive support for their difficulties and very few refusing help. There are many positive aspects of working with this client group, with the prison setting providing a real opportunity to engage those who may not have sought help from community services. Treatment offers the opportunity to develop more helpful coping strategies which they can use on release, and provides the space for their feelings and anomalous experiences to be validated. The benefits of mental health support are perhaps best expressed by 'Femi' again: 

'I felt free. If I didn't have help… I'd be wayward… mentally I would shut myself down…I would just isolate myself.' 

Everyone benefits

Improving mental health care in prisons could also have a wider range of benefits. For prison employees it may mean that fewer demands are placed on them to manage difficulties associated with undetected mental health problems. Mental health services can also contribute to safer custody within the prison, helping to identify prisoners with risk issues and ensure they receive appropriate support. And there could be wider implications for society as a whole, with prisoners receiving the most appropriate treatment for their needs rather than these problems going undetected and contributing to reoffending. The growing appreciation of the beneficial impact that early identification of mental health needs can have is reflected in a recent pilot scheme to place mental health nurses in prisons/courts (tinyurl.com/ovfncbw).
There is still a long way to go in ensuring the needs of prisoners with mental health problems are met. However, the introduction of early detection services can help identify and treat mental health difficulties within the prison population and offers continuity of care between prison and the community.

Anna Roberts is a Research Worker with the OASIS in Prison Team, Institute of Psychiatry, London
[email protected]

References

Barnes, T.R., Leeson, V.C., Mutsatsa, S.H. et al. (2008). Duration of untreated psychosis and social function: 1-year follow-up study of first-episode schizophrenia. British Journal of  Psychiatry, 193, 203–209.
Brooker, C., Sirdifield, C. & Gojkovic, D. (2007). Mental health services and prisoners: An updated review. University of Lincoln/CCAWI. (Commissioned by the Prison Health Research Network)
Brugha, T., Singleton, N., Meltzer, H. et al. (2005). Psychosis in the community and in prisons. American Journal of Psychiatry, 162, 774–780.
Casswell, M., French, P. & Rogers, A. (2012) Distress, defiance or adaptation? A review paper of at-risk mental health states in young offenders. Early Intervention in Psychiatry, 6(3), 219–228.
Forrester, A., Henderson, C., Wilson, S. et al. (2009) A suitable waiting room? Hospital transfer outcomes and delays from two London prisons. The Psychiatrist, 33, 409–412.
Harvey, J. & Smedley, K. (2010). Psychological therapy in prisons and other secure settings. Oxford: Willan. 
Jarrett, M., Craig, T., Parrott, J. et al. (2012). Identifying men at ultra high risk of psychosis in a prison population. Schizophrenia Research, 136, 1–6.
Marshall, M., Lewis, S., Lockwood, A. et al. (2005). Association between duration of untreated psychosis and outcome in cohorts of first-episode patients. Archives of General Psychiatry, 62, 975–983.
Office of the Deputy Prime Minister (2002). Reducing re-offending by ex-prisoners:  London: Author.
Office of the Deputy Prime Minister (2004). Mental health and social exclusion. London: Author. 
Reed, J. & Lyne, M. (2000). Inpatient care of mentally ill people in prison. British Medical Journal, 320(7241), 1031–1034. 
Shaw, J., Baker, D., Hunt, I.M. et al. (2004). Suicide by prisoners. British Journal of Psychiatry, 184, 263–267.
Singleton, N., Meltzer, H., Gatward, R. et al. (1998). Psychiatric morbidity among prisoners. Office of National Statistics. 
Yung, A.R., Yuen, H.P., McGorry, P.D. et al. (2005) Mapping the onset of psychosis: The Comprehensive Assessment of At-Risk Mental States. Australian and New Zealand Journal of Psychiatry, 39, 964–971.
Yung., A.R., Yuen, H.P., Berger, G. et al. (2007). Declining transition rate in ultra high risk (prodromal) services. Schizophrenia Bulletin, 33(3), 673–681.