Dr Graham Durcan, our Associate Director of Research and Evaluation, speaks to Thea Joshi about mental health in prisons. The Centre has done decades of research in this area but, despite some good progress, in some ways prisons are less safe than they were 15 years ago. Graham discusses the findings of our new report about mental health care for people in prisons, and why a fundamental culture shift is needed to ensure prisons are focused on rehabilitation and wellbeing.
- Report: The future of prison mental health care in England
- Report: From prison to work
- Our work on trauma-informed care
- Learn more about Liaison & Diversion services
- You can support our work here
Music by scottholmesmusic.com
Alethea Joshi (AJ): Hello, and welcome to Centre for Mental Health’s podcast, where we talk about a whole range of topics around mental health and social justice. I’m your host, Thea Joshi, and in each episode we talk to people with lived experience, people working in a specific area of mental health, or our own team, to share what we’re doing in the fight for mental health equality. The other day I caught up with Graham Durcan, our longest-serving research director, to talk about the mental health needs of people in prison. This is an area we’ve been working in for decades and we have seen some good progress – but so much more still needs to be done. Graham talks about our new report looking at mental health services for prisoners, and what needs to change. We know that most people in prison have some form of vulnerability or needs, whether that’s a mental health difficulty, neurodiversity or a substance misuse problem. So what we explored here was this idea that prisons not only need better training, greater continuity of care, and all these other really crucial things, but also that prisons need a total cultural shift towards rehabilitation and wellbeing.
So I’m really pleased to be here today with Dr. Graham Durcan, our Associate Director of Research and Evaluation. Hello, Graham. It’s so great to have you here. So, Graham has overseen much of our research over the years, and especially into mental health and criminal justice and the mental health needs of the prison population. And that’s mainly what we’re going to be talking about today. So we launched just last week, a new report called The future of prison mental health care in England. And Graham can tell us a bit more about that. So Graham, it would be great if you could just give us a basic overview for people who don’t work in this field. Tell us a bit about people in prison, the prison population, what are the key mental health needs that we tend to see?
Graham Durcan (GD): Well, it’s probably broader than just mental health, there’s a variety of vulnerabilities related to mental health. I think we’ve known for ages that the vast majority of prisoners have sort of multiple and complex needs. And if we’re talking about mental health, addiction, personality disorder, we’re talking about the bulk of the prison population. But on top of that, there’s a variety of other vulnerabilities that are highly prevalent. So they sometimes get sort of labelled as neurodiverse conditions, but we’re talking about things like, it’s very likely there’s a significant proportion of the population have got acquired brain injury. So just like all these other conditions that will affect decision making behaviour, how they think about how they think and see things; ADHD, attention deficit hyperactivity disorder, again, it’s going to affect decision making, thinking, behaviour. And we’ve got various learning difficulties and learning disability represented in the prison population as well. Autism, so there’s a whole range of conditions, including all of the full gamut of sort of mental health conditions, you know, we will have psychosis, perhaps 5, 6% of the overall population will have a psychotic condition. But we’re talking sort of, you know, 90%, of the prison population. And I think the really important thing to bear in mind is that it’s seldom one problem that they have, it’s a multiplicity of problems. And that makes it all the more complex, so multiple vulnerabilities. I mean, frustratingly, when you look at individual problems that many prisoners will have, they’ll often fall just below the threshold for entry into a service so they can be helped for that problem. But because of all the other vulnerabilities they’ve got, they tend to be really still very disadvantaged.
AJ: Thank you Graham, that was a really helpful overview. So could you talk us through some of the main issues which are really preventing better mental health among people in prison?
GD: Yeah, absolutely. It’s a really good question. And it’s obviously what our report is focused on and, you know, towards the future, what can improve? I think one of the main recommendations is about training. And it’s more than just giving mental health awareness training, I think say for prison officers and other prison staff, a really significant overhaul of their training needs to take place, that’s my view, or that was the view that’s come out of our review. Because I just don’t think they have adequate training in the population, understanding, recognising vulnerabilities, and understanding what impact those vulnerabilities will have on the way that person thinks, and the way that person behaves. All of that is quite important if you want to rehabilitate the person, but just also for security, etc. And it’s also important around improving mental wellbeing because another big theme in the report is, you can’t outsource the responsibility for mental wellbeing to the NHS, you know, so the NHS are in there to add expertise and add value, and provide specific services, etc. But actually, if the bulk of the population have these multiple complex vulnerabilities, then it’s got to be the responsibility of the host organisation, the prison, it’s got to be their responsibility for overall wellbeing and wellbeing is more than about treatment.
It’s about an environment. So we’ve got some real problems in some of our prisons in terms of the physical environment, lots of old prisons that are not just not particularly conducive to sort of wellbeing. But I think the training thing is quite important. So significant overhaul, but I also think probably I don’t know that anyone is particularly well trained for working in a prison, even the health care staff, there is not specific training say for nurses around prison mental health care, education staff, any other staff, any of the voluntary sector organisations ought to be able to access, staff, that just introduces them to vulnerabilities, and knows what impact those vulnerabilities can have on the way that person thinks, feels and behaves.
Other things are really important as well. Information, continuity of information, continuity of care. So people may be getting treatments for all sorts of conditions in the community, that can get really disrupted when they come into prison because of failures in communication with community services, be those mental health services, GP services, hospital services. So that’s a real issue. And the fault is probably on both sides to a degree; you got very small health care teams in prisons, and their capacity to sort of outreach and chase information. So having, you know, bringing together information systems is really important.
I suppose the other big sort of thing that we pick up in the report is leaving prison. We know an awful lot of people will reoffend, fail in other ways, you know, just have very difficult lives immediately upon leaving prison. So we know we’ve not had fully functioning rehabilitation probation services for quite some time. We know those are coming back into the public sector. But again, it’s an upheaval. So that’s a real issue. And there are just you know, continuity of care. So very often, for instance, [if] you’ve got a mental health problem, you probably will start to get it treated, if it’s a severe mental health, certainly, well, you’ll probably get it treated in prison. But then we talked about that issue of meeting thresholds out there in the community; often, they won’t have any care to move on to. And we found that in our review, and other work that we’ve done as well, even people with what we’d say are quite severe mental illnesses, fell below the threshold for entry, say to a community mental health team. Now there’s positive news on the horizon. So NHS England are currently funding a thing called RECONNECT, a programme which will engage people before they’re leaving prison, follow them ‘through the gate’, and then for a period in the community will sort of bridge them into other services, etc, and attempt to provide some sort of wraparound care for that person, so they don’t fail and fall to the wayside.
AJ: Thank you so much for that. Graham, I think that’s so important to get that overview of needs and what needs to be happening. I mean, the tragic thing is, is that some of it seems, I know it’s very, very complex to actually roll out, but some of it seems quite obvious, you know, that people who are living with multiple vulnerabilities in prison, that the people working with them, looking after them, keeping an eye on them, would have training, to know how to support them. It’s like, of course, that’s absolutely vital. But obviously, we haven’t seen that for so long. And I know we did some work a few years back, about helping people leaving prison into work through Individual Placement and Support, and I’ll link to that in our show notes. And what we were seeing that was that people with quite severe mental health needs, were getting nothing as leaving prison and then, that feeling of, are we just setting people up to fail?
GD: I’m gonna add one thing if I can, around sort of within prison, what happens… So I mean, the NHS commissions mental health care services, and it tries to do that, it has what’s called a stepped care type model. So you know, providing self help, guided self help, right through to providing in some places, inpatient unit care, and everything in between, so psychological therapies, etc. One thing that’s probably always struck us, and it has improved is just the variability of the sort of the mental health offer. So you’ll find kind of ‘islands of excellence’ so they’ll have a really good kind of therapy service in this prison, but they don’t have another element of service. And that’s what we found as well. And particularly around talking therapy, psychological interventions. So you know, the recommendations we’re making to say NHS England, the commissioner, is around standardising that offer of care. And we’re doing a second exercise with a needs analysis of mental health services across the prisons, which is going to do a lot more counting, so a lot of survey work. It’s almost a ‘part two’ to this exercise. And that will help quantify that need a bit more and quantify what skills and teams we have to meet that need and where the gaps are.
AJ: Fantastic. So I don’t want to take us off on too much of a tangent, Graham, but I noticed in the report, a phrase that really stuck out to me that came through Prison Reform Trust, this concept of ‘prison as punishment’ versus ‘prisons for punishment’. And I kind of wonder if you could talk a bit about those differences in approach and how that perhaps affects the approach to mental health care for prisoners.
GD: Absolutely, I mean, it does dramatically affect the wellbeing. And also, you know, it affects the culture of a prison as well. So I think most people, when you sit down and sort of talk them through things, will agree that the purpose, the punishment element of prison is the deprivation of liberty. And thereafter, what we expect our prisons to do is support people to rehabilitate and get them on the correct path. And that can be, you know, helping them geting to appropriate treatments and things like that. But also training them for work and educating and a variety of other things, anything that’s likely to get them on the sort of right path, less likely to reoffend when they leave prisons. And it’s a natural reaction, when we hear about a horrible crime, you want, you sort of naturally want the prison to be punishing, and you know, ‘throw away the key’. And I think that’s often steered by a part of our media, the sort of angry reaction type thing. It can affect politicians. But ultimately, what it boils down to is you can have quite a negative culture within the prison, which is not conducive to rehabilitation, and actually changing people, which is what we think prisons should be about.
AJ: Thanks, Graham, that’s really helpful. And I guess connected to that, we’ve done quite a lot of work in the past few years about trauma-informed work and trauma. And we know that’s a big issue in the prison population. Can you tell us a little bit more about about that, and why we’re advocating a trauma-informed, psychologically-informed approach?
GD: Okay. I mean, interestingly, this is something that’s so highly significant, you know, the experience of trauma, both among prison staff, and then people in prison. So I think you need to say take a sort of a joined-up approach. So in the review, we found a really positive association with collaborative working with different agencies in the prison, more positive attitudes and greater responsibility from prison staff around mental wellbeing where there’d been sort of acceptance and training of these trauma-informed approaches. And why do we want to do this? Well, an awful lot of the prison population have experience of trauma, there’s good research on that. And that impacts their wellbeing every day. And prisons are, you know, it’s very difficult for a prison not to retraumatise a person. So being aware and minimising that impact is actually going to improve someone’s wellbeing, but I also bring attention to prison staff, they witness and see routinely quite traumatic things. So prisons are very violent places, you know, 1000s of staff will experience assaults, etc. And that will have an impact on some of them for much longer than others have. And that’s, that’s how trauma affects some people more than others. So I think that’s something that needs to be addressed as well. So having, trauma-informed, being aware of trauma, trauma-informed training for staff, yes, around their own issues, but also around the issues for prisoners’ understanding, once again, it’s about understanding vulnerability. It’s about understanding how trauma can impact on how someone thinks and how they behave, how they react to certain situations, and just being sort of armed for that with knowledge.
AJ: That is so helpful, Graham, and yeah, we’ve got we’ve got an awful lot on our website about trauma-informed care in different settings. But it’s very obvious that it is especially vital in a prison setting. And so yeah, thank you for speaking to that. I’m really interested to know, as you know, a lay person coming to this. Is it that people are coming into prison with higher levels of mental health need? Or is it that being in prison really has an impact on their mental health? I mean, it may be both, and I know that’s quite a reductive question. I’d love to know if there’s an answer.
GD: The answer is yes. It’s both. It’s both of those things. So you’ll have a significant number of people who bring their pre existing problems with them into prison, multiple and complex needs. Often untreated, unrecognised initially, and for some people the first time it gets recognised, the first treatment they get when they come into prison, which is, you know, it’s sad to say that, you know, you have to come come into prison to get treatment. But also, yeah, prison does have an impact on people. I mean, overall, if you get treatment you’re likely to improve. But there are going to be particular groups of people, those who are in for longer, those who don’t have determined sentence, where that uncertainty will impact on them as well. You know, prisons can be very violent and distressing places, we’ve had very high suicide rates, sort of record rates in recent years. And self harm has been really, really, really high now; it went down initially, during the period of the pandemic, however, up until that point, self harm incidents – recorded self harm, and we probably don’t record everything – were really, really high and, you know, achieved record levels. And as I said there, prisons are very violent places, all of that can impact on someone’s ongoing wellbeing. You know, family relationships break down when someone’s in prison for any length of time, people lose their jobs through coming in for prison. So there’s lots of reasons why there can be challenges to someone’s mental wellbeing while they’re being in prison.
AJ: Thank you for that Graham, that’s a really helpful explanation. And I guess it really speaks to, again, the need for better preventative care in the community as well, because as you say, it’s quite appalling that people are only getting support for their mental health when they get to prison. I mean, that’s a real flaw in the whole system. But yeah, so thank you for that. You touched on the pandemic there. And, yeah, could you tell us a little bit more about how COVID has affected prisons and people in them and the mental health needs of them?
GD: Prisons have been dramatically affected by COVID, just just like all other aspects of our life. So I mean, I’ll go through a list of things that have happened. So prison visits stopped. And whilst you know, there had been action since to increase access to telephones so they can have contact, you know, that increases the isolation and distance between family and community of people in prison.
Prisoners have had to spend sometimes days on end in cell, and certainly 23 hours a day. The prison service rightly sought to increase the number of prisoners in single cells to reduce, you know, the spread of Covid-19. However, if you’re locked up for more than 22 hours a day and you’re in a single cell, that’s effectively, under the Mandela rules, the sort of international rules, that’s solitary confinement. Solitary confinement has a dramatic impact, negative impact on mental wellbeing, that’s pretty well established.
And the other thing, of course, were those who were accessing treatments, those treatments had to stop, because there was a shortage of safety equipment, PPE. Most health services weren’t able to run routine treatments, talking therapies, things like that. So eventually, there were more health checks or staff coming to doors, talking to people through the hatches and things like that. But those aren’t exactly a replacement. So some prisons were very innovative. So, you know, some cells and some prisons have telephone points, so you can move a telephone unit in, and prisoners have cards so they can make calls to a limited range of numbers, normally family, etc. But what they did was, you know, added therapists to the phone cards, so they could then do therapy, whilst they were in their cells, so you know, that’s kind of great. But I think overall, the sort of digital explosion that we had out in the community just really was a lost opportunity in prisons. But NHS England are addressing this now and have purchased 1000s of licences, as well as equipment that’s approved, to go into digital equipment, tablets, etc. So we can do more digital stuff, or we’ll be able to in the future, do assessments where need be. But, you know, digital is one way that we might be able to broaden the therapeutic offer, you’ll remember I talked about earlier about the variability of therapeutic offers, particularly around things like talking therapies. Well, you know, digital is one way that we might be able to, because it doesn’t matter where the therapist is, you know, they don’t have to be on site there, they could be hundreds of miles away and still do the therapy. So, you know, it’s a pity that we weren’t able to do that sort of experimentation during the period of pandemic, but it’s looking up for the future.
I mean, other things to just think about, you know, prisoners, not getting out the cells, not doing any activities at all. So all of that will have had an impact on wellbeing.
We also know that some racialised communities are over-represented in the prison population. We know too, that those racialised communities suffered more in the community, more infections, more deaths etc. So again, we should expect the community within prison also to be affected. So there may be a greater number, a disproportionate number of those communities that may suffer bereavements. And maybe more of those bereavements will be what we call sort of ‘complex grief reactions’. So that’s where, you know, generally, grief is not a mental illness. It’s a normal human emotion after a loss. But I think under normal circumstances, about 7%, of bereavements are quite complex for whatever reason. And I think the pandemic, both in the community, and certainly [when] we’re talking about prisons, may produce more complex bereavement reactions, because people have not been able to have contact with loved ones, haven’t been able to go to funerals, so on and so forth. So dealing with the loss may be more difficult.
AJ: Thank you so much, Graham, for shedding light on that. And you were talking there about kind of specific groups and inequalities within the prison population. And I guess, just as in wider society, what we see is intersections of inequality and disadvantage. So there’s a lot more in our report about that, and looking at specific groups as well and their needs. But I just wanted to ask you more broadly, we know that you’ve been working in the area of mental health and criminal justice for a number of years now. And I just wondered if you’ve kind of seen key changes or trends over that time?
GD: Absolutely. And I, you know, I think there’s a lot to be celebrated has been a vast improvement in health and justice services. It’s been very helpful over the last decade to have a single Commissioner for, you know, what goes on in courts, a health commissioner for what goes on in courts, police custody, and in prisons, across youth justice; that’s been really, really helpful. So it’s, it has brought more standardisation. So just over a decade ago, you know, one of the things I would have been talking about, about just how inconsistent things were, different models, all sorts, well that’s starting to improve. So let’s just talk through some of those improvements.
So 100% of our youth justice teams, of our courts, of our police custody suites, now have a liaison and diversion service commissioned by NHS England. And that’s very often an NHS organisation, but there are voluntary sector organisations that are a key part of that as well. And we know from the limited research where there is at least one study, Eddie Kane and colleagues from Nottingham, that appears to demonstrate that not only does it bring sort of health and wellbeing benefits having liaison and diversion services, but it actually reduces offending, I think, pretty much for across any age group, because we know the liaison & diversion services are all age, across any offending type, that seems to be the evidence that’s come from that study. So very positive impact, it’s great, we’ve got that. It also means that increasingly, better information, if someone has been screened by liaison & diversion service, and is going to be remanded into prison, then better information will come with at least some of the people coming into prison. And I’ve noticed that in some some areas. So that was a finding in London that we’ve picked up on, great communication or improving communication via those liaison & diversion services.
We have a national specification for mental health care that will be getting revised or gets regularly revised. So we’ve got a consistent model that services need to follow, which is fantastic. There has been an increase in mental health services across prisons now; there’s huge variability, so there’s a long way to go yet. It’s not all there. But we we seem to think at all levels now. So it is not just the severe mentally ill, but you know, lots of people will fall below that threshold. And so there are sort of improved primary mental health care services as well.
I think there are some groups that we need to do even more for, so people with personality disorders, if they’ve committed a very high risk offence, and if they’ve got a very severe disorder, which is the minority, they are likely to be in the Offender Personality Disorder Programme, which is sort of jointly run between the NHS and Ministry of Justice. And yeah, they get sort of great treatments there. But the bulk of prisoners with personality disorder aren’t in that. And I think they’re a great unmet need. As I said previously, there are some great examples that are islands of excellence in some prisons, doing great work, great talking therapies, you know, adapting what we do in the community and working with that particular group. That’s fantastic.
So there’s there’s other improvements, you know, thinking about sort of youth violence, public health approaches around knife crime and gang related crime, etc. All of those, you know, taking the lessons learnt in Scotland where a lot of those ideas in the UK at least have been developed, and more broadly taking on all of these, and the NHS and you know, health services very much becoming a part of that. So, yeah, there are lots of improvements and lots of things to celebrate.
AJ: It’s really encouraging to hear that Graham, because as you say, there is obviously a really long way to go. And by no means any of us can be resting on our laurels, anytime soon, because you’ve highlighted very clearly there all of the needs that are yet to be met, and the difficulties facing prison mental health care. But it is encouraging to hear, for example, about the progress in the rollout of liaison and diversion services, because I know that’s something that we’ve done a lot of work on over the past decades, and a lot of campaigning about to make that a reality. So that’s really encouraging. You were talking about the investment needed in better care for people in prisons. But we have heard a lot recently in political rhetoric about the need for investment in bigger prisons, more prisons, more prison places. I wonder if you want to ‘bring us into land’ by commenting on that for a moment.
GD: Yeah, I mean, probably the direction we’re moving in, in terms of prison sizes is the wrong direction. In our view, I’m afraid small is beautiful. When it comes to prisons, if you want to successfully rehabilitate anyone, you need to really build a relationship with that person that models future relationships in that person’s life. And I think whilst there’s an obvious attraction in bigger prisons, because you, you might get savings through economies of scale, it’s very difficult to deliver those sort of relationship-based services. And that’s health care services, rehabilitation services. It’s very difficult to do it on a large scale. So yeah, we’d like to see smaller prisons. And we’d like to see, you know, a better focus on rehabilitation. And I think, I think you need greater investment in smaller scale establishments.
AJ: Graham, thank you so much for joining us today, for giving us a kind of crash course in mental health among people in prison. There is so much more that we could say about this topic, and we’ll definitely have to have you on the podcast again. But for now, I’ll link to this report in the show notes. Yes. And yeah, thank you so much for your time.
GD: Thanks Thea. And thanks everyone for listening.
AJ: Hope you enjoyed the episode. You can find out more about our work on mental health and criminal justice by visiting our website. And to join us in the fight for equality in mental health, please donate at www.centreformentalhealth.org.uk/donate. See you next time.