Influence of environmental factors on mental health within prisons: focus group study
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7413.480 (Published 28 August 2003) Cite this as: BMJ 2003;327:480
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I greatly welcome the initiative of Dr Nurse and colleagues in
drawing further attention to an important subject. As their conclusions
are of value beyond the UK, I hope that their article is widely
disseminated in the prison systems of Europe. It could however have
included reference to the "Mental Health Promotion in Prisons Consensus
Statement" published in 1998 by the WHO Health in Prisons Project, based
in Copenhagen, with its partner organisation Mental Health Europe.
This
Report includes a management checklist which, if followed, would
considerably help to reduce the impact of environmental factors on mental
health in prisons.A copy of the Statement and other information about the
work of the WHO HIPP can be found at:
www.hipp-europe.org
Alex Gatherer
Competing interests:
Acting as temporary consultant to the WHO Health in Prisons Programme
Competing interests: No competing interests
Dear Editor,
Following on from the prison focus group study by Nurse et al (1)
conducted in 2000, a number of changes have occurred in Winchester Prison.
The initial findings of the focus group study were used to develop a
Health Improvement Programme for the Prison based on the views of the
community with a health promoting ethos(2,3). This has led to the creation
of a prison-based part-time health promotion specialist.
A number of initiatives have been introduced that potentially improve
prisoner and staff mental health by addressing factors in the wider prison
environment: An in-reach Community Mental Health Team has since been
developed to work with prisoners with mental health problems and aims for
equivalence of care with the NHS. A NGO provides mental health training
for prison staff, (though limited prison resources have limited the number
of prison officers released for training). An on-going occupational health
pilot project succeeded in halving the previously high staff absenteeism
rate, which contributed to breaking the circle of stress. ‘Enhanced
Thinking Skills Programme’ and the ‘Control Your Anger and Learn to Manage
It’ courses, have been introduced to tackle recidivism by challenging the
way that prisoners cognitively process their perceptions of the world
around them, and allow them opportunities to develop and practise new
strategies. These courses have the potential to impact upon the spiral of
negative relationships between staff and prisoners.
Focus groups conducted in 2002 in the same prison, confirmed that
isolation and lack of activity remained key factors impacting negatively
on the mental health of prisoners, despite the prison having one of the
highest levels of purposeful activity of any local prison in the region.
The work which was available was seen as dull and repetitive (e.g. fitting
chains to ball point pens). Findings suggested that relationships with
prison staff had improved, thereby diffusing the circle of stress.
The restricted use of the telephones remained a source of frustration
and stress for prisoners, and further meant loss of free time out of cells
spent queueing. Poor access to telephones and limited visiting hours
exacerbated already strained family ties. The issue of bullying of
vulnerable prisoners by other prisoners remained a high priority for this
group. There were reports of social distance between members of different
ethnic groups, and derisory references to gay prisoners.
While progress has been made in addressing prisoner mental health
through changes in the prison environment, barriers remain. Winchester
Prison has now been included in the Prison Service’s performance
improvement strategy and this initiative, at a time of rising population,
may in the short term, further contribute to the ‘circle of stress’.
References:
1. Nurse J, Woodcock P, Ormsby J ‘Influence of environmental factors
on mental health within prisons: focus group study’ BMJ, 2003, Vol. 327,
30th August, pp.480-483.
2. ‘Health Promoting Prisons: A Shared Approach’ Department of Health,
www.doh.gov.uk/prisonhealth (accessed 22.09.03)
3. Health in Prisons Project, Europe ‘Mental Health Promotion Statement on
Prisons’ WHO, Europe, http://www.hipp-europe.org/events/hague/0042.htm
(accessed 24.09.03).
Authors:
Jo Nurse, Specialist Registrar in Public Health, Health Policy Unit,
London School of Hygiene and Tropical Medicine, London, WC!E 7HT. Email:
jonurse66@hotmail.com
Simon Blasby, Senior Health Promotion Specialist (Prisons), Mid
Hampshire PCT Health Promotion Service, Highcroft, Romsey Road,
Winchester, Hampshire.
Jim Gomersall, The Governor, HM Prison Winchester, Romsey Road,
Winchester, Hampshire.
Paul Woodcock, Health Promotion Specialist, Public Health
Directorate, Western Sussex PCT, Bramber Building, 9 College Lane,
Chichester.
Jim Ormsby, Consultant Forensic Psychiatrist, Ravenswood House,
Knowle, Fareham, Hampshire, PO17 5NA.
Competing interests:
None declared
Competing interests: No competing interests
I have worked in the medical clinic of a Canadian prison for women
(remand, medium security, and high security) since 1994. I concur with
the findings of this study, and complement the authors on their work.
That high risk behaviour, leading to the transmission of blood bourne
pathogens, occurs when addicted men and women are locked up in prison, is
well-known. However, the reasons why some inmates become drug addicted
during their incarceration, are less well known. This study adds to our
understanding.
We will only succeed in increasing our understanding of prisoner ill-
health if we design consultative studies, such as this one, in which
prisoners and prison staff tell us their stories. Similarly, we might
succeed in improving prisoner health if we invite prisoners and prison
medical staff to give input into the design, and implementation, of prison
health interventions.
Competing interests:
None declared
Competing interests: No competing interests
The authors of this study are to be congratulated for highlighting
what I knew as a prison senior medical officer and head of health care.
Prisoners with dual diagnosis of mental illness and substance abuse have
more complex needs, let alone in prison. Despite having the clientele
under one roof prisons will miss the opportunity to implement integrated
care programmes for comorbid prisoners and to address more complex needs
of homelessness, blood borne viruses, suicidality and to make lasting
psych-social interventions that would ultimately reduce harm to the
individual from illicit drug use, and harm to society from re-offending.
The ethics of managing a patient in conditions akin to seclusion apart,
the tasks of engaging and retaining of prisoners in treatment and
facilitating re-introduction into the unsuspecting community become more
difficult. It might be that we as a society need to shift our emphasis to
an agenda involving human values of prison staff and prisoner/patients
alike, and by focusing more on these we can help both through more
appropriate resourcing. We might then right claim to have a moral mandate
for putting mentally disordered offenders in prison.
References:
1. Jo Nurse, Paul Woodcock, and Jim Ormsby
Influence of environmental factors on mental health within prisons: focus
group study
BMJ 2003; 327: 480-0
2. Models of Care for treatment of adult drug users. Part 2: Department of
Health. www.nta.nhs.uk
Competing interests:
None declared
Competing interests: No competing interests
Editor
Nurse Woodcock and Ormsby's paper is a welcome qualitative study
providing factual confirmation of a fact that has long been opinion. The
HM Inspectors of prisons in Scotland and England and Wales have repeatedly
pointed out the detrimental effects of isolation and lack of quality
programmes. Having worked in HM Cortonvale prison for 23 years before
becoming Deputy Minister for Justice in the Scottish Executive I was very
concious of the need for community based solutions particularly to drug
related crime where custody often worsened associated mental health
problems and also according to Home office research provided
opportunities to establish networks for future drug dealing
The Scottish Prison Service [SPS] in its 'Key performance indicators'
agreed with the Scottish Executive have substantially increased the hours
available to prisoners for education work and courses addressing offender
behaviour. The SPS has successfully exceeded the targets set.
However the increasing numbers of short term prisoners, especially
those on remand and the increasing numbers with a drug or drug and alcohol
problems has made the task of the SPS more difficult.
The other major factor in preventing a solution to this problem in
Scotland is the requirement on the SPS to provide an escort service to
court. This overriding requirement often removes substantial numbers of
officers at short notice from the prison interrupting all programmes. The
Scottish Executive have responded by taking the power in the most recent
Criminal Justice Bill [2003] to transfer escort duties out of the current
SPS.
The courts continue to remand increasing numbers of prisoners and to
imprison large numbers for two weeks or less for fine default and many
more for less than 3 months [in Scotland around 6000/25000 male admissions
for fine default and 600/2200 female admissions with similar numbers for
remand]. These short term prisoners then re-offend in over 40% of cases
young offenders in nearly 70% of cases This approach to remand and
sentencing is ineffective both in punishment terms and in preventing re-
offending. It is extremely expensive (>£28,000 per prisoner per annum
£36,000 for women).
For many custody should be replaced by a community based approach which
avoids the additional damage done to prisoners especially those with pre-
existing mental health problems and will reduce ultimately the damage to
society and the burden on prison services caused by short periods of
custody.
Community solutions should include bail hostels, community reparation
orders[proposed in the 2003 manifesto by the Scottish Labour party],
'Time Out ' 'treatment' centres of which the first for women offenders
with drug problems will be opened in Glasgow this autumn treating 500
short term offenders annually, and electronic tagging on remand . These
measures should be combined with more imaginative custodial approaches
including admission for some non-violent offenders at a time when
overcrowding permits instead of immediately, overnight custody and weekend
prison with sentences calculated in hours rather that weeks or months.
All of these measures would reduce overcrowding and allow the prisons
improve prisoner management reduce isolation and address re-offending
behaviour.
Until we stop overcrowding our prisons with those who have drug problems
and are in custody for too short a time to benefit from 'treatment'. Until
the personal development plans required for each prisoner includes an
entitlement [in the absence of contravention of prison rules] to minimum
access to out of cell activities, the problem of isolation will continue
to be a problem.
Competing interests:
None declared
Competing interests: No competing interests
Should assisted suicide be an option for prisoners?
Judging from the outcry following Shipman's suicide it would seem
that there is basic need to see justice being done and for revenge in the
case of violent crimes. That is neither a civilised nor a Christian
response. The only justification for imprisonment and capital punishment
should be the prevention of new crimes. If this were to be accepted by the
public the offer of assisted suicide would aid in accomplishing that
objective in an humane way.
Shipman's suicide was premeditated and very carefully planned and
executed judging from the way he managed to give the impression he was
looking forward to see his wife for his birthday. He had clearly concluded
that he was not going to prove his innocense and was likely to spend the
rest of his life in a hell-hole. In making sure that his wife was not left
destitute he did the honorable thing. His actions have certainly saved the
state a lot of money.
Competing interests:
None declared
Competing interests: No competing interests