The big issue: Working behind bars
Therapy Today, December 2021 / January 2022

Poor mental health in prisons comes with deadly consequences – self-inflicted deaths are nearly nine times more likely in prison than in the general population. Every five days a person in prison takes their own life, and 70% of these people have already been identified as having mental health needs.¹ According to a recently released report from the House of Commons Justice Committee, the ‘disjointed and incoherent approach’ to care in UK prisons has left many prisoners suffering from mental health issues without access to treatment or diagnosis.² ‘When you look at the data, poor mental health is spread right across the prison estate,’ says Andy Bell, Deputy Chief Executive of the Centre for Mental Health, a mental health campaign and analysis group. ‘There are multiple and complex needs across the population.’

The recent TV drama Time, said by many in the industry to be true to life, painted a brutal picture of a typical UK prison – noisy, violent, overcrowded and overrun with drugs. The challenges facing the UK prison system are well documented – underfunding has led to staff shortages and high staff turnover, and the prison structure itself is often made up of overcrowded, run-down buildings, where prisoners spend hours locked up with nothing to do.

Prison culture, where distress, self-harm and suicide attempts can often be seen as manipulative, rather than indicators of need and vulnerability, contributes to an unsafe environment, according to a 2017 report by the Howard League.³ This unsafe environment also exposes professionals working in prison to multiple potentially traumatising experiences, which negatively impact their own wellbeing and the care they can provide, and in turn contribute to a prison environment that is unsafe and non-rehabilitative.

There is growing concern that the situation is spiralling out of control. It’s clear that improving the prison environment is fundamental to improving prisoners’ mental health. But until that happens, how can we as a profession support vulnerable prisoners? Do traditional talking therapies have a viable role in UK prisons, and if so, what are the challenges we face in effectively delivering such services?

Unmet needs

One of the challenges highlighted by the Justice Committee report is the practice of using prisons as a ‘place of safety’ for those with acute mental health needs when mental health services are inadequate or absent in the community. The prison population also has a high proportion of people with learning disabilities, as well as those from marginalised groups who may have a higher level of unrecognised and unmet mental health need. Yet, according to a report by the Prisons and Probation Ombudsman (PPO), concerns about mental health problems are only flagged on entry for just over half of affected prisoners. It also found that nearly one in five of those diagnosed with a mental health problem received no care from a mental health professional in prison.⁴

In fact, screening for mental health issues at prison reception is often done by a staff member, who may have limited training in mental health, according to a recent report from the Centre for Mental Health, The Future of Prison Mental Health Care in England, commissioned by NHS England and NHS Improvement.⁵ It also found that, although the national specification for prison mental health care sets out a stepped-care model, there appear to be large disparities and the threshold for accessing secondary mental health care is even higher than it used to be.

Adapting to prison constraints

Counselling has a key role to play, but providing talking therapies in prisons is not straightforward – Bell points out that prisoners may be moved without notice, or serving a very short sentence. ‘Knowing that, it’s important to think about brief interventions that can be useful – almost psycho-educational opportunities,’ he says. ‘At the other end, you have people who have very long, and even indeterminate sentences, including some for whom long-term therapy is potentially very helpful.’

There are also fundamental logistical problems with providing counselling in prison, says BACP Vice President John Cowley, who has a long-standing interest in this area and set up BACP’s Criminal Justice Forum (currently inactive). ‘In prison, people’s experience is both chaotic and regimented,’ he says. ‘And if the prison officers decide something won’t happen, it won’t. Or someone may have a single session and then be moved. Prisons are very noisy places, and it’s very difficult to find places for private conversations.’

Gaining trust

A further challenge is gaining the trust of prisoners. It’s essential that counselling services are seen to be run by an external provider and separate to the prison system. Counselling also needs to be the prisoner’s choice; autonomy is scarce in prison, points out Andy Bateman, lecturer in counselling at the University of Bradford, who has extensive experience of prison work. ‘In prison, if you’re lucky, you get to choose what you have for dinner or whether you go out of your cell,’ he says. ‘Prisoners need to experience what it feels like when they choose not to go to counselling.’

Prisoners are also a user group who may have low expectations of how talking therapy can help. ‘The people you’re working with typically don’t have experience of good professional relationships, such as in schools and education,’ says Peter Stevens, Head of Psychological Therapies at Greenwich and Kent prisons for Oxleas NHS Foundation Trust. ‘They also may have no real concept of what psychotherapy is.’

There needs to be a lot of reassurance work before therapy starts, says Emma Coulson, a service development manager for The Forward Trust, specialists in working with addiction, who deliver IAPT services in prisons in London, Hertfordshire, Essex and Suffolk. ‘We do an induction session for all potential clients before they start any work, and we talk about what they want and how it’s a collaborative process. We talk about expectations and the process, and how they can stop at any point. And to make it prison specific, adapted to the environment they are in, we have changed the language in our workbooks to make them more accessible. It’s about normalising what we’re going to do, the different approaches, any concerns they’ve got about the term “therapy” and so on.’

Bateman says that therapeutic work in prisons doesn’t always need to be provided by counsellors – the key is that the person can be trusted. ‘I think there are lots of people offering what we might think of as counselling services, who we might not necessarily think of as counsellors. What is needed is someone who will come in and sit in front of a person in distress, and in prison that may well be based in the chaplaincy,’ he says. Listening schemes, a Samaritans initiative that trains prisoners as peer supporters, also provide a key service for prisoners at risk of self-harm and suicide.

Reaching this client group also means thinking beyond traditional one-to-one work. ‘Lots of men who have kids will hook onto parenting classes because they probably haven’t had very good parenting themselves and have a fantasy of how things will be when they come out. There may be a way of working counselling into that, in terms of how to be a man and how to build relationships with your family,’ says Cowley. He has also had surprising success with teaching guided relaxation exercises to prisoners. ‘However it’s delivered, I think there is a space for something that teaches prisoners how to manage their thoughts and find a safe space in their head.’

Stepped approaches

All prisoner healthcare is provided by the NHS. The stepped-care model of mental health common in the community is also applied in prisons and is flagged as best practice in the Centre for Mental Health report.⁵ But, just as in the community, therapeutic work is often delivered by psychologists and mental health nurses.

The first step typically involves short-term interventions and guidance for people to support their own mental health. The second moves up to groupwork, involving different approaches over several weeks; the third involves one-to-one CBT work; the fourth, multidisciplinary support for people who have been given a formal diagnosis, and step five is for people with the most severe mental illness.

Steps one to three effectively mirror IAPT provision in the community, with some important differences. ‘We’re in a very different setting, working with people with a level of need who wouldn’t be appropriate for IAPT anyway,’ says Dr Janet Swift, Psychology Lead for Devon Partnership NHS Trust, working with prisons across Devon. ‘However, we are very clear that this is a space to think about their mental health, the same as for anyone in the community. Our focus isn’t on their offending behaviour or their risk to others. I think we present a really clear message that the service is part of the NHS, not the prison. We’re also very clear that there is some specific information we might share with the prison but otherwise the service is confidential.’

Referrals come from staff who have contact with incoming prisoners on reception, but anyone who works in the prison service can refer a prisoner at any time. ‘Prison residents can also self-refer. There is no barrier for them coming in – that’s our aim,’ says Sarah Krys, Service Manager for Prison Mental Health for Devon Partnership NHS Trust. ‘One of the things we see in prisons is that, if we involve prisoners, it lends more credibility to the service. We’re working on employing peer support workers – prisoners who are currently serving a sentence, who do an initial training programme and are paid for their involvement. We hope in future they’ll be able to co-deliver and even deliver some of the groupwork.’

As is increasingly the case in the NHS in general, roles for therapists within this stepped model are limited. A psychotherapist may supervise therapeutic groups for prisoners, for instance, but the groups will be delivered by assistant psychologists. Experienced psychotherapists may also be involved at stage four, the equivalent of a referral to a community mental health team, but not always. ‘At this stage we’re often looking much more at the medical model, with access to a psychiatrist, possible prescribing and/or transfer to a secure mental health hospital. Talking therapies may be involved here too if it’s appropriate for the individual,’ says Swift.

At the same time, there is also increasing recognition that most prisoners have experienced significant amounts of trauma and adversity in their lives. ‘We are interested in how that manifests in, for example, PTSD or anxiety,’ says Dr Laura Blundell, clinical psychologist and senior psychological therapist with Oxleas NHS Foundation Trust. ‘That’s the core of our model, that we’re always thinking about trauma-informed delivery, and we’ve done a lot of work training operational staff in how we’re working with a complex client group that has experienced significant trauma.’ Oxleas follows a similar stepped-care model to the Devon one, and it’s at stage three or four that longer-term psychotherapeutic interventions are brought in. ‘The approaches we usually take are predominantly trauma-based such as EMDR or trauma-focused CBT. Step four is when a longer-term programme of 10 to 16 sessions of psychotherapy or counselling might take place.’

Voluntary and independent-sector counselling services can tender to provide IAPT and other NHS services in prisons. The Forward Trust, for instance, provides substance misuse sessions in 21 prisons across the UK, as well as IAPT-style provision in five of the 21. ‘Most of our referrals wouldn’t have been accepted onto IAPT in the community,’ says Emma Coulson, ‘as a lot have a number of disorders and they may be misusing substances and/or medication. We have flexible criteria.’

Working through shame

NHS services aside, much of the counselling in prisons is provided by small services local to the prison, often initiated by individual practitioners in response to need. Mo Smith, a BACP senior accredited counsellor, set up and manages a counselling service at HMP Stocken, a Category C prison in the East Midlands, which she has documented in her book Journey to Release: counselling in a UK prison (Waterside Press). The service is currently staffed by 19 counsellors, half qualified and half trainees. ‘We listen to prisoners without judging them, and we help them understand who they are and what is behind their behaviour. We ask for client feedback at the end of a series of sessions. One prisoner said that counselling “helped to solve real time problems – I have to do the last bit on my own”. Another said, “It helped me understand that it is OK to love myself”.’

But, at the moment, many of the counsellors involved in prison work do so on a voluntary basis due to budget constraints. As Smith says, ‘No matter how much a prison governor may be behind the service, if there isn’t enough money in their budget, they can’t pay for it. I do prison work because it is rewarding and I know it is needed. The volunteers who work with us may initially come to get their clinical hours, but they stay because they love the work. You are making a difference to some of society’s most disadvantaged people, most of whom have suffered abuse and trauma. A common theme is that trainees say they feel privileged to do the work. As one said, “No two sessions are the same and it certainly keeps me challenged in a positive way.” Another described how he always comes out of sessions feeling elated that he has enabled the client to have insight into themself.’

Smith only takes on counsellors or trainees with a background in support work or with at least 50 documented clinical hours. ‘Trainees also need a letter from their tutor saying they’re fit to practise in this setting,’ she says. ‘There is also a prison induction process highlighting security and safe practice before they start with clients, and very close support by a line manager and a supervisor. I think all trainees need nurturing, and if they’re going to work in prisons and be safe, they need that nurturing to be very specific.’

Training

There is no doubt that working with the prison community is complex and challenging – and also very isolating, says Peter Jones, BACP Fellow. He set up the Counselling in Prisons Network (CiPN) in 2007 to support counsellors working within the criminal justice system. They often feel ‘unsupported and with little acknowledgment of their work or, in some cases, their actual existence as professionals’, he says. Part of the CiPN five-year strategy is to promote the development of a co-ordinated, formal, UK-wide academic network to provide accredited training for prison counselling.⁶ Jones says his vision is that there will be a postgraduate diploma for therapists working in the prison setting. ‘Students need to be adequately prepared before they go into that setting, and they need to be quite aware of the whole prison context,’ he argues.

Right now, the training is gained ‘on the job’, which is why the right supervision is key, says Smith, ideally from a supervisor with experience of the prison service. There also needs to be an awareness that prison counselling is not appropriate for every counsellor, says John Cowley: ‘There are all sorts of hidden dangers. Prisoners have nothing to do all day, so one of the games is to find out as much as you can about the person in front of you. Quite conversational questions – Where did you come from? Did you have a nice weekend? – appear very innocent but actually give away quite a lot that could be used against you. It’s an environment where counsellors really have to have their wits about them. Counsellors need supervision from someone who knows about prisons and knows about the risks.’

As Peter Stevens says, counsellors in prisons are ‘working in an environment that is traumatising in itself. You’re sending people back into that, at the end of the session, whatever you do.’

Changing the currently fragmented approach to counselling in prisons starts with taking stock, says Cowley, and finding out how many counsellors are working directly with offenders. ‘Around 10 years ago, when I was Chair of the BACP Criminal Justice Forum, I met with Professor Louis Appleby, then the UK’s first “Health and Criminal Justice Tsar”. He asked how many BACP members worked in the prison system, and I had to admit that we did not know. If the same question was asked today, the answer would be the same. The most powerful thing BACP as a membership body could do now to support counsellors working in prisons is to find out how many are doing this work. Then we can plan how to support them in their valuable work to change lives.’

This data collection is underway. From October 2020, BACP began distributing a Workforce Mapping Survey to all renewing members to build up a picture of the employment landscape, and within this there is an option to indicate prison work.

Talk to any counsellor who has worked with prisoners, and they will tell you how important it is. Many believe, like Smith, that counselling has a key role to play in preventing reoffending and it should be part of the rehabilitation process of a prison sentence. ‘Counsellors give the clients something they have not had before – the chance to be heard,’ she says. ‘We work with prisoners to help them accept the circumstances that have been beyond their control, as well as explore how they look at their future, and that is potentially life changing. I have a firm belief that there is a need to have quality counselling services within our prisons and I have seen for myself their value and importance.’ Time will tell whether this role becomes universally recognised – and remunerated accordingly – and if counselling in prisons evolves in a way that makes it sustainable for counsellors.

Are you offering therapeutic support in prisons? We are interested in hearing from you – email therapytoday@thinkpublishing.co.uk