Psychological Therapy in Prisons and Other Settings

Joel Harvey, Kirsty Smedley, Joel Harvey, Kirsty Smedley

• Publisher: Willan
• Year: 2012
• ISBN:
  9781136681240
• Edition: 1
• Topic: Psychologie
• Subtopic: Forensische Psychologie

This book examines a range of therapeutic approaches used in prisons and other secure settings and explores the challenges in such work.

The approaches include Cognitive-Behavioural Therapy (CBT), Cognitive-Analytic Therapy (CAT), Attachment-Based Psychodynamic Psychotherapy and Systemic Psychotherapy. It provides insights into debates about providing therapy in prisons and other secure settings and discusses specific topics such as mental health in-reach teams, working with women in prison, therapy within therapeutic communities and therapy with black and minority ethnic groups.

This book addresses developments in mental healthcare by the National Health Service (NHS) within prisons and on-going policy developments which aim to improve access to psychological therapies for prisoners. The contributors draw on experience both in clinical psychology and forensic psychology, as well as psychotherapy and criminology. They draw on experience too in a range of environments, including juvenile and young offender establishments, local prisons and dispersal prisons.

Psychological Therapy in Prisons and Other Secure Settings will be essential reading for people who work to improve the psychological wellbeing of individuals in prisons and other secure settings.

Chapter 1

Introduction

Joel Harvey and Kirsty Smedley

In 2001, the government document Changing the Outlook: A Strategy for Developing and Modernising Mental Health Services in Prisons (DH and HMPS 2001) set out a five-year plan to improve the health care provision of prisoners. This document put forward the principle of ‘equivalence’, in that ‘prisoners should have access to the same range and quality of services appropriate to their needs as are available to the general population through the NHS’ (DH and HMPS 2001). In 2006 the transferring of commissioning responsibility from the Prison Service to the NHS was completed. Mental health in-reach teams (MHIRTs) were introduced between 2003 and 2006 in order to support prisoners with severe and enduring mental health problems. In practice, MHIRTs have taken a broader remit and have also attempted to meet the needs of prisoners with a range of mental health difficulties including depression, self-injury and post-traumatic stress disorder (PTSD), to name but a few (see Bradley 2009). However, there still remains a high level of unmet need (Durcan and Knowles 2006; SCMH 2009) and although there are now some primary care services offering psychological therapy (e.g. HMP Liverpool) it is argued that there is still a need for more primary care services within prisons (SCMH 2007; SCMH 2009). In 2009 the Department of Health published the document Improving Access to Psychological Therapy (IAPT) Offenders Positive Practice. This document, aimed at commissioners of IAPT services, states that ‘IAPT services should be available and effective for both men and women who come into contact with the criminal justice system, as well as those who are at risk of offending’ (DH 2009: 4). In recent years there has been a move to set up IAPT services in prisons, as for example in HMP Brixton, but this work is in progress.

At a policy level steps have thus been taken to stress the importance of meeting the needs of prisoners, although how these needs are met in practice is another complex question. It is important to state at the outset of this book that the psychological needs of offenders far exceeds the mental health resources available to meet those needs (Brooker et al. 2008). To receive psychological therapy in prison remains a rare occurrence given the number of prisoners who could potentially benefit from a therapeutic intervention (Brooker and Gojkovic 2009). Nevertheless, we must not underestimate the valuable work that is being carried out across prisons in England and Wales. In fact, this book sets out to examine a number of different therapeutic approaches that are used in prisons and other secure settings in England and Wales and to offer insights into the challenges of such work.

Prisons and other secure settings are psychologically demanding environments which require people to draw upon a range of internal and external resources in order to survive. There are 138 prisons in England and Wales and they vary in function, size, architecture, security classification and whether they are run by the public or private sector (see Jewkes 2007; HMPS 2010). There are also four private secure training centres for young people aged between 15 and 17. On 30 June 2009 there were 83,454 people in prison; of these 79,158 were male and 4,292 were female (Ministry of Justice 2009). The rate of imprisonment in England and Wales has almost doubled since January 1993, despite crime rates remaining relatively stable (PRT 2009). Indeed, Jewkes and Johnston (2006) argue that the UK has developed ‘a deep cultural attachment to the prison’(p. 284). In addition to over 80,000 prisoners in custody, there are 3,937 ‘mentally disordered offenders’ detained in hospital settings in England and Wales (Ministry of Justice 2010).¹ In 2008 the number of people transferred from prison to hospital was 926 (Ministry of Justice 2010), although it has been recognised that on average there were 262 prisoners waiting to be transferred to an NHS hospital who were still in prison (Bradley 2009). This book also makes reference to therapy provision within these medium- and low-secure hospital settings.² Considering secure hospital settings alongside prison helps to tease out the issues that are specific to therapy provision within the prison environment.

The Mental Health Needs of Prisoners

It is well documented that people who are in prison have a number of psychological difficulties (Singleton et al. 1998; Fazel and Danesh 2002; Rickford and Edgar 2005; HMCIP 2007; Bradley 2009; Corston 2007; Romily and Bartlett 2010). And as well as having mental health needs, and yet related to those needs, many prisoners suffer great social exclusion (Social Exclusion Unit 2002). The Social Exclusion Unit (2002) found that prisoners differed from people in the general community, in that: 27 per cent of prisoners were taken into care as a child (compared to 2 per cent of the general population), 32 per cent were homeless (compared to 0.9 per cent of the general population), 67 per cent were unemployed before coming to prison (compared to 5 per cent of general population), 65 per cent had numeracy difficulties and 48 per cent had reading difficulties (compared to 23 per cent and between 21 per cent and 33 per cent of the general population respectively). It is important that these needs are met, alongside mental health needs, in order to improve prisoners’ quality of life and sense of well-being. Indeed, a holistic approach to the care of prisoners is needed in order to bring about psychological change.

Analysing the mental health needs of prisoners in more detail, Singleton et al. (1998) found that 90 per cent of prisoners had a diagnosis of at least one mental disorder. These difficulties include depression, anxiety, psychosis, PTSD and personality disorders (see Mills and Kendall, Chapter 2, this book). It has been found that the prevalence rate for psychosis is between 6 per cent and 13 per cent (Singleton et al. 1998) among prisoners compared to 0.4 per cent of the general working population (Singleton et al. 2000). A prevalence rate of between 40 per cent and 76 per cent was found for neurotic disorders (Singleton et al. 1998) compared to 17.3 per cent in the general working population (Singleton et al. 2000). Singleton et al. (1998) found that between 50 per cent and 78 per cent of prisoners reached the criteria for a personality disorder compared to between 3.4 per cent and 5.4 per cent in the general working population (Singleton et al. 2000).

Adams and Ferrandino (2008) state that ‘the most common mental illnesses in the inmate population are depression, schizophrenia and bipolar disorder, a finding that applies to prisons in both the United States and the United Kingdom’ (p. 914). It has also been found that a high proportion of prisoners have had problems with substance misuse prior to entering prison (Singleton et al. 1998; Brooke et al. 2000; Liebling et al. 2005; Fazel et al. 2006). Fazel et al. (2006) found that the prevalence rate for alcohol abuse and dependence ranged between 18 and 30 per cent for male prisoners and 10 to 24 per cent for female prisoners. Prevalence rates for drug abuse and dependency ranged from 10 to 48 per cent for male prisoners and 30 to 60 per cent for female prisoners.

Moreover, as mentioned above, many people with mental health difficulties in prison may require hospital treatment but, due to a shortage of hospital beds, experience severe delays in their transfer (see Rickford and Edgar 2005). For these individuals imprisonment is not an appropriate place for treatment, and their needs may not be fully met until they are transferred to a hospital setting.

A large proportion of prisoners experience a high level of psychological distress (Liebling et al. 2005; HMCIP 2007; Harvey 2007). A thematic review by Her Majesty’s Chief Inspector of Prisons (HMCIP) found that 65 per cent of women and 52 per cent of men obtained high scores on the GHQ-12, a screening tool for psychological distress (HMIP 2007). Extensive research has also been carried out in relation to self-harm and suicide in prisons (Liebling 1992; Shaw et al. 2004; Jenkins et al. 2005; Leese et al. 2006; Liebling 2007). During 2007 there were 22,459 recorded incidents of self-harm; women accounted for 54 per cent of these incidents (PRT 2009). Over 100 prisoners were resuscitated after serious self-harm and 92 completed suicide (PRT 2009). Fazel et al. (2005) note that the number of prisoners completing suicide has risen between 1978 and 2003; prisoners are five times more likely to complete suicide than people in the general community are.

Dear (2008), in a review of his own research over the past 10 years in Australia, concludes that ‘self-harming behaviour occurs in a context of heightened distress and one of our central findings was that prisoners who self-harm report poorer coping responses than do those who do not self-harm’ (p. 469). He found that prisoners self-harmed following different precipitating factors. They divided these factors into five main groups: a stressful event within the prison, a consequence of imprisonment (e.g. missing a family member), an event occurring outside prison, psychological symptoms (e.g. PTSD symptoms) and aspects of the wider criminal justice system. The first category, a stressful event occurring within the prison, was the most cited reason for self-harm. Dear (2008) put forward five broad recommendations to prison authorities in order to help prevent self-harm in prison: removing aspects of the prison environment that are associated with high levels of self-harm; screening prisoners for the vulnerability factors to self-harm; enabling prison staff to detect prisoners’ distress; providing interventions in order to improve prisoners’ ability to cope; and, for the management, focusing on supporting distressed prisoners (rather than focusing solely on physical barriers). The role of psychological therapy in prison is also of relevance to the reduction in suicide and self-harm.

The Psychosocial Experience of Imprisonment

For some people, imprisonment might seem an opportunity for stability and containment away from a difficult and confusing life outside; however, it is sad that imprisonment, with its loss of freedoms, can seem the best opportunity one has. And far more people find imprisonment to be challenging and destabilising. Although prisons differ in their ‘quality of life’ (see Liebling 2004), and although individuals react and cope differently with being in custody (see Adams 1992; Liebling and Maruna 2005), undoubtedly the prison presents practical, social and psychological challenges to many of them. Indeed, as Liebling and Maruna (2005) state, ‘fear, anxiety, loneliness, trauma, depression, injustice, powerlessness, violence and uncertainty are all part of the experience of prison life’ (Liebling and Maruna 2005: 3). Bullying is prevalent in custody (see Ireland 2002) and can be a precipitator to self-harm (Liebling 1992; Dear 2008). Rickford and Edgar, in their review of the mental health needs of men in prisons in the UK, concluded that ‘prisons cause social isolation, subjecting people to danger and idleness, failing to respect their human dignity, and maintaining them, too often, in inhumane conditions’ (Rickford and Edgar 2005: 29).

The pains of imprisonment are pervasive and include the deprivations of liberty, goods and services, heterosexual relationships, autonomy and security (Sykes 1958). Sykes states that ‘however painful these frustrations and deprivations may be in the immediate terms of thwarted goals, discomfort, boredom, and loneliness, they carry a more profound hurt as a set of threats or attacks which are directed against the very foundations of the prisoner’s being’ (Sykes 1958, cited in Jewkes and Johnston 2006: 172). Jamieson and Grounds (2005) remind us that ‘the prisoner’s time (lost out of a finite life span) is not counted among these pains or losses’ (p. 52) and that the pains of imprisonment can extend into the prisoner’s life postsentence through enduring changes in their personality.

Across the period of imprisonment, the entry period has been found to be an acutely painful one, characterised by concerns about separation and loss, a lack of safety, uncertainty, and a loss of freedom (Liebling 1999; Harvey 2007). In a study of young men adapting to their first month in prison, Harvey found that those prisoners who had the most difficulty regulating their emotions and who had higher levels of distress upon entry found it most difficult to adapt to life in prison over time. They had a more painful experience of imprisonment, were more determined by their environment, and found it more difficult to seek and accept any help that might have been on offer.

One of the most extensive studies to be carried out examining this entry period, and prisoners’ adaptation subsequently, was carried out by Zamble and Porporino (1988). In their longitudinal study of prisoner adaptation in Canada they interviewed male prisoners a few weeks after their reception into custody and followed up after four and sixteen months. At the first time interval prisoners were having a difficult time and experienced high levels of distress. However, several problems were identified from interviews carried out after a few weeks in prison. These were coded into the following categories: missing their family and friends; missing their freedom; missing a specific object or activity; conflicts with other prisoners; regrets about the past; concern with the future; boredom; cell conditions; medical services; a lack of staff support; a concern with safety; and a lack of programmes or activities. Indeed, being apart from family and friends was cited as the most difficult problem for prisoners during the first two weeks.

The interaction between the individual and the environment is important in determining the prisoners’ experience. Toch (1977) argued that in order for an individual to adapt to life inside and to survive psychologically there has to be a match between an individual’s needs and the environment. Toch identified seven needs which were the needs for: safety, privacy, structure, emotional feedback, support, activity and freedom. When there is a ‘fit’ between the individual’s needs and the environment’s ability to meet these needs then successful adjustment may occur. It could be argued that the provision of psychological therapy may go some way to meeting the emotional needs of prisoners. Moreover, Liebling et al. (2005), in their evaluation of the safer locals programme,³ found that both self-reported levels of pre-existing vulnerability (e.g. previous self-harm, substance misuse, psychiatric problems) and also aspects of the quality of the prison environment contributed to levels of prisoner distress. Indeed, ‘levels of distress were associated with relational dimensions (including relationships with staff, respect, fairness), dignity, frustration, family contact and participating in offending behaviour programmes and personal development activities’ (Liebling et al. 2005: 10). The environment thus clearly matters in relation to the experience of imprisonment. Furthermore, it appears that the environment can offset the distress experienced by ‘high vulnerability’ prisoners. Liebling et al. (2005) found that ‘high vulnerability’ prisoners (that is those with a history of psychiatric difficulties and self-harming behaviour) showed less distress when they had more time out of cell, more employment, fewer cancellations of association, greater opportunities of contact with family members and an opportunity to participate in offending behaviour courses. When specifically considering pr...