Elsevier

Health & Place

Volume 29, September 2014, Pages 179-185
Health & Place

Mental health/illness and prisons as place: Frontline clinicians׳ perspectives of mental health work in a penal setting

https://doi.org/10.1016/j.healthplace.2014.07.004Get rights and content

Abstract

This article takes mental health and prisons as its two foci. It explores the links between social and structural aspects of the penal setting, the provision of mental healthcare in prisons, and mental health work in this environment. This analysis utilises qualitative interview data from prison-based fieldwork undertaken in Her Majesty׳s Prison Service, England. Two themes are discussed: (1) the desire and practicalities of doing mental health work and (2) prison staff as mental health work allies. Concepts covered include equivalence, training, ownership, informal communication, mental health knowledge, service gatekeepers, case identification, and unmet need. Implications for practice are (1) the mental health knowledge and understanding of prison wing staff could be appraised and developed to improve mental healthcare and address unmet need. Their role as observers and gatekeepers could be considered. (2) The realities of frontline mental health work for clinicians in the penal environment should be embraced and used to produce and implement improved policy and practice guidance, which is in better accord with the actuality of the context – both socially and structurally.

Introduction

Mental health care provision within the UK occurs within a complex system of different providers (statutory, private and third sector) and tiers of service (primary care or specialist services) (Nicaise et al., 2012). This complicated web of services and structures has been highlighted by authors such as Gask and Lester (2008) and Nicaise et al. (2012) as leading to fragmentation and in some cases duplication in care delivery. For individuals in prison establishments, this system is even more challenging to navigate as there is an additional interface between NHS healthcare health care appraises and the public prison service that covers England and Wales.

Within Her Majesty׳s Prison Service (HMPS), prisoners are entitled to healthcare (including mental health services) which may be provided by NHS, private or third (voluntary) sector services. However, ‘prison settings are a challenging environment in which to manage and deliver healthcare’ (Powell et al., 2010: 1263). Thus, research that explores the issues of health and place in this setting and appraises contemporary problems in this field of healthcare provision is timely and relevant. As deViggiani (2006) argues prison healthcare services are in need of development.

Nurse et al. (2003: 484) identifies that ‘there is a high prevalence of mental health problems in prisons and insufficient provision for these problems’. Psychotic disorders reportedly affect 7% of sentenced male prisoners in comparison to 0.5% of men societal wide (Jewkes and Johnston 2006: 229). Ten per cent of men and 30% of women have had a previous psychiatric admission prior to prison (Edgar and Pickford, 2009). In the United States of America the Department of Justice (James and Glaze, 2006) state that more than 56% of State prisoners, 45% of Federal prisoners and 64% of jail inmates have a mental health problem. Co-morbidity is also an issue within prisons. Many prisoners have a complex mix of mental and physical health problems and the use of alcohol or illicit substances may complicate their situation further.

The mental illness profile of HMPS׳s prisoners as a group remains ‘under-recognised, not high enough on the public health agenda and a constant daily nightmare for prison systems’ (Fraser et al., 2009:410). It has been demonstrated before that context is crucial in relation to the conduct of mental healthcare in a prison setting (Jordan, 2010). Gojkovic׳s (2010) national study of mental health provision and organisation in English prisons reports a tension for mental healthcare staff in relation to ‘delivering care in a punitive environment’ (p. 284). Indeed, ‘the provision of mental healthcare and the pursuit of good mental health in the prison milieu are challenging’ (Jordan, 2011, p. 1061). It is therefore appropriate to devote further attention to social and institutional structures that permeate the prison setting and affect mental health services (Jordan, 2010).

For mental health patients in a prison setting ‘mental healthcare receipt experiences and environments are important’ (Jordan, 2012a: 722). As debated in this article, the same is true for mental healthcare provision and those frontline providers/staff who undertake mental health work in penal settings. For the prison healthcare clinicians involved in this study, the nature of health and place is salient for both political and personal reasons. ‘The delivery of mental healthcare within the prison system is a complex process’ (Brooker and Birmingham, 2009, p. 1); reasons for this place-orientated complexity are explored in this article.

The analysis presented in this paper is drawn from a larger piece of work which evaluated the mental health commissioning and providing arrangements within three male HMPS establishments. This project also explored the met and unmet mental health needs of prisoners. To maintain confidentiality it is not possible to name the establishments in this publication. Within the UK and NHS more generally, the provision of healthcare is split into organisations which “commission” services and those which provide them. In brief, commissioning refers to the planning and purchasing of services (from the NHS, private and third sector organisations) to meet the health needs of a local population (The Kings Fund, 2011). DH and HMPS (2001) Changing the Outlook: A Strategy for Modernising Mental Health Services in Prisons officially introduced the principle of equivalence to prison mental healthcare. The equivalence strategy calls for prison mental healthcare to be in-line with the range of community based mental health services available beyond the prison setting.

Part of the wider project involved using qualitative research methods to explore the experiences of providing mental healthcare in the prison setting by frontline healthcare staff (further details of the participants are included later). Semi-structured interviews were conducted across three HMPS sites. This paper uses some of the fieldwork data to develop the literature surrounding mental healthcare in the prison setting (Jordan, 2010b). Jordan (2012b) identifies that there are numerous methodological issues with using interviews to collect data. These include “the structure of interview questions, participant unfamiliarity with the process, body language and non-verbal communication, plus discussions concerning conversational turn taking and interviewee agency” (Jordan, 2012b). Therefore, interviews were conducted sensitively in the prison settings and methodological aspects were reflected upon by the researchers (Jordan, 2012b). The study team was based at the Centre for Health and Justice at the Institute of Mental Health and included a mental health nurse, sociologist and a specialist in secure services provision.

In summary, the contributions of this article are fourfold. First, we address a neglected area in the literature relating to the experiences of providing mental healthcare within penal settings. We build on the existing evidence base by discussing the role of primary and secondary/specialist healthcare staff groups in providing mental healthcare to the prison population. We use concepts of personal desire and political practicalities to explore mental health work in the prison setting. This is a novel approach not addressed in previous studies. Second, we highlight the barriers and facilitators to mental health work in this specific context. Third, we identify the important role played by social relationships and informal networks (rather than, for example, formal healthcare procedures) within the setting which are used to manage prisoners׳ mental health needs. Finally, we discuss the roles and responsibilities of prison wing staff in relation to mental health work.

Section snippets

Fieldwork and participants

Participants were recruited from primary and secondary healthcare services. They included both mental health specialist staff, for example Registered Mental Health Nurses (RMNs), Clinical Psychologists and Psychiatrists, as well as non-specialist staff such as Registered General Nurses (RGNs) and General Practitioners (GPs). Within the prison setting (as in the wider community) a distinction is made between primary care, comprising mainly physical healthcare and some short term, mental health

Results and discussion

As stated previously the analysis presented here draws on work from a larger study and has four aims: (1) to explore the experiences of staff in prison settings of providing mental healthcare, (2) to discuss the barriers and facilitators to mental health work in the prison context, (3) to look at the role of social relationships and informal networks, and (4) to consider the role of wider prison staff. Two overarching themes were identified from the data which explored mental health work in

Conclusion

The prison as a setting for mental healthcare presents a number of distinct challenges for those involved in the provision of services. This paper has focused on the experiences of both specialist mental health and primary care clinicians. It is acknowledged that a limitation of the study is the lack of interviews with prisoners themselves and any future research should endeavour to include those incarcerated within HMPS. We have also highlighted the importance of context to the provision of

Acknowledgements

The healthcare staff at the prison establishments are thanked for their time and participation in this project.

References (27)

  • A. Fraser et al.

    Mental health in prison: great difficulties but are there opportunities?

    Public Heath

    (2009)
  • M. Jordan

    The prison setting as a place of enforced residence, its mental health effects, and the mental healthcare implications

    Health Place

    (2011)
  • C. Brooker et al.

    The psychiatric aspects of imprisonment revisited

    J. Forensic Psychiatry Psychol.

    (2009)
  • DH et al.

    Changing the Outlook: A Strategy for Modernising Mental Health Services in Prisons

    (2001)
  • DH

    Offender Mental Health Care Pathway

    (2005)
  • DH

    Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

    (2008)
  • K. Edgar et al.

    Too Little, Too Late: An Independent Review of Unmet Mental Health Need in Prison

    (2009)
  • S. Forrest et al.

    Shaping pre-registration mental health nursing education through user and carer involvement in curriculum design and delivery

  • L. Gask et al.

    Working together. invited commentary on the primary care management of anxiety and depression

    Adv. Psychiatric Treat.

    (2008)
  • D. Gojkovic

    Factors Influencing the Organization of Prison Mental Health Services: A Cross-National Study

    (2010)
  • C. Grbich

    Qualitative Data Analysis: An Introduction

    (2007)
  • D.J. James et al.

    Bureau of Justice Statistics Special Report. Mental Health Problems of Prison and Jail Inmates

    (2006)
  • M. Jordan

    Embracing the notion that context is crucial in prison mental healthcare

    Br. J. Forensic Pract.

    (2010)
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