Reducing Suicide and Deliberate Self Harm
Exploring experience: a discussion process
4 Prisons
There were three strands of discussion, the first relating to issues that spanned the prison service, the second and third to particular issues and concerns for Cornton Vale and for Polmont Young Offenders Institution. There was limited input to the discussion process from Barlinnie.
4.1 Scottish Prison Service
The Prison Service's ACT strategy on suicide risk management aims to address risk of suicide and suicidal behaviour and promote a caring environment where those in distress can ask for help. The strategy was said to have helped create an ethos of care and support in prisons. A major programme of training was introduced to support implementation, with annual refresher training. In addition, procedures were introduced to detect, assess and manage risk. ACT is said to have promoted multidisciplinary team working, with an understanding that reducing suicide and self harm and promoting mental health is everyone's business and a responsibility that prison officers share with health colleagues. The introduction of case conferences provides a forum for review and communication, involving the prisoner, prison officers and health care staff. ACT policies are now being reviewed and updated, partly because it is thought that people may be getting 'over-familiar' with the process.
Despite the progress described within prisons over recent years, the prison service remains concerned that the gains achieved when someone is in custody are forfeited in view of what happens on release. The accessibility of support and the high level of health care in custody are often not matched when prisoners return to the community.
Approach
In addressing suicide and self harm, the following features of the Scottish Prison Service (SPS) approach appear important and may have resonance in other settings:
The focus on mental health and well being is viewed as an integral aspect of SPS' work, not a specialist area for medical staff alone. To bring this about is reported to have required top down commitment coupled with opportunity for local establishments to develop ownership. Time and effort have been invested in raising awareness and building skills and trust
A holistic approach, going beyond presenting problems, providing a range of supports
The creation of a culture of care, with a proactive approach to prevention - 'it is OK to talk about feeling suicidal, people know they will get help'
Emphasis on promotion and prevention - dealing with suicide has moved beyond the immediate resort to anti-ligature cells for observation to a point where it is now more about the relationships between staff and prisoners
Potential opportunity within the prison environment to spot issues and problems and to act early
Evidence of effects
People who self harm are no longer 'patched up' and punished with loss of remission
There has been a reduction in the number of people put on ACT procedures as identified risks - assisted by the introduction of mental health teams and the prisoner listener scheme (see below)
Prisoners themselves are more actively involved in their own care planning and case conferences
Prisons are still working on developing links with local communities, organisations and groups including faith groups
Listener scheme
This involves prisoner volunteers, trained and supported by the Samaritans, providing a confidential listening ear for fellow prisoners. Prisoners can ask to see a listener. Listeners are able to go to different parts of the prison. The exchange between listener and prisoner remains entirely confidential. Listeners can call the Samaritans if they need to talk about issues that occur in an encounter with another prisoner.
The scheme was introduced in the last 12 months and development has been variable in different establishments. Strategic will has not always been evident in the translation into practice. Some prisons have 10 listeners, others none.
In Cornton Vale there are problems with retaining listeners as women move on.
Staff report that women like the scheme as it gives prisoners more ownership of problems and solutions. Data collected in Cornton Vale indicate the scheme is used to help with problems or worries relating to issues outside prison and not so much by people who are actively suicidal.
In Polmont, listeners are not currently involved with people in anti-ligature cells, although this is under consideration.
In Barlinnie, the scheme met with suspicion when first introduced, with concerns about confidentiality. Staff were said to be reluctant to support it initially. However, there is now much stronger backing. Statistics demonstrate that its increasing use has been accompanied by a fall in the number of people on ACT. It is thought to have taken time for trust and credibility to develop.
4.2 Cornton Vale
On a given day there may be 10 women categorised as high risk and another 30 as low risk. Assessment on arrival includes implementation of ACT strategy where indicated, with risk assessed by Prison Officer, Nurse and Doctor. However, experience has suggested that if someone knows the system and has firm intent to harm herself then ACT cannot necessarily avoid this happening.
Self harm is a significant issue for many of the women prisoners in Cornton Vale. The approach taken by the Prison Service is to manage risk of self harm very differently to risk of suicide. Placing a woman who self harms in an anti-ligature cells would be likely to make things worse.
There are plans within Cornton Vale to establish an ' enabling day care model' for people with self harm issues, where the person would work with an RMN, or other mental health professional. This is not envisaged as a unit in a separate part of the prison but a way of providing tiered therapeutic service that manages contact more effectively and provides capacity to do constructive work with high risk groups.
The mental health team in Cornton Vale has an open referral system. Uptake of the team is considerable. A third of the women seen have anxiety problems, a small proportion have a severe and enduring mental illness. A large number have personality disorder or drug related problems.
Through and after care
Cornton Vale is considered to have good relationships with mental health services and has in-reach from psychiatrists and forensic CPNs. The prison recently held an open day for all providers of acute psychiatric services and IPCUs. There are established links and liaison arrangements with IPCUs and other hospitals to which prisoners may be referred. Links with GPs are reported to be good.
A range of voluntary organisations come into the prison to provide support - Open Secret, Rape Crisis, CRUSE, Samaritans.
Challenges of prevention
Experience within the prison suggests that if someone is intent on self harming, procedures cannot stop this. Unless people are locked up in an inappropriate manner you cannot exclude risks. This is regarded as a debate for society to have and not just an issue for SPS to resolve. Media coverage persists in focusing public and political attention on suicide incidents. Fatal Accident Inquiries can be a good forum in which to put across the view that suicide is society's problem and that it is for society to deal with.
Two relatively recent suicides in Cornton Vale occurred after a 4 year gap, which is considered by the service as a remarkable achievement. The prison would wish to see a shift in focus to look at what can be achieved, rather than criticising and blaming. The alternative may be that the service retreats into proceduralism, and a reliance on defensive practices, with loss of capacity to provide care and support to those who require it. There is a need to enhance support for staff caring for a highly vulnerable group of people. The 200-plus women in Cornton Vale are among the most vulnerable people in Scotland.
4.3 Polmont Young Offenders Institution
Mental Health Team members act as named links, assigned to each hall. This make the Team more accessible to prisoners who can self refer or speak informally. The team provides early intervention and support, and follows up anyone placed on ACT procedures because of risk.
On release, the team makes every effort to ensure follow up appointments are made and information is passed on to the person's GP or consultant psychiatrist. There can be problems with long term prisoners who do not have a GP, where the person is on medication. Staff cited the example of one young man on depot medication for schizophrenia, who left prison with no identifiable doctor in the community.
An increasingly wide range of therapeutic work is undertaken, including complementary therapies and art therapy. The initial scepticism these elicited are said to have been largely overcome. Members of the MHT have a range of specialist therapeutic skills.
Over time, prison officers are reported to have become more confident about supporting people at risk without immediate resort to formal measures. Staff described how, through supportive relationships, they have been able to manage behaviours, which would previously have led to invoking ACT procedures, and to work with the person on factors that trigger self harming behaviours.
Staff attribute this to the fact that they feel more empowered themselves and have developed the trust and confidence to assume responsibility. They have been able to take the original ACT strategy further than was envisaged.
A point of concern was raised by staff about transitions for prisoners coming from the private establishment at Kilmarnock. It has been found that the same level of attention to risk assessment and management was not evident in the practices of Kilmarnock staff with responsibility for transferring prisoners into the SPS establishment.
4.4 Barlinnie
Through care issues are a major concern for people on remand. For those serving a sentence, there is increasing contact with their GP and follow on contact from the forensic CPN service.
The pressures associated with transitions (see earlier) are manifest in Barlinnie, sometimes in surprising ways. Recently a number of prisoners in the 'top end' of the prison, due for release required support from the mental health team. For graduates from Polmont, arrival in Barlinnie is said to be a huge culture shock.