Dangers of Being ‘At Risk’

From Samaritans.org

…Alternative Measures for Suicide Prevention in Prisons

The 2017 report from the Ombudsman investigating the use of physical restraints for prisoners accommodated in At Risk Units (ARUs) has revealed some shocking details about the care of the suicidal in New Zealand prisons. Whilst much of the attention following from the report has understandably focused on the torturous use of tie down beds and wrist restraints, questions remain about the reliance on ARUs in general to accommodate and manage suicidal and self-harming prisoners.

In the last three years more than 700 prisoners have been through these units (McCulloch 2017). In ARUs, prisoners are placed in cells with minimal fixtures, a mattress and an unscreened toilet. In these ‘environments of deprivation’ (Stanley 2017), they are stripped of their usual clothing, given an untearable gown and bedding, and placed under 24-hour camera observation. Interaction with others, including staff, is highly limited.

Corrections protocol states that prisoners in ARUs should ‘have the same opportunities for involvement in prison activities as other prisoners, consistent with maintaining their safety and the safety of others’ (Ombudsman 2017:12). However, the Ombudsman team ‘found no evidence of at-risk prisoners taking part in any form of structured activity or intervention’ (2017:14) or engaging in strategies to manage and address their self-harm or suicidal thoughts. In only one case did ‘at risk’ plans contain referrals to other services such as chaplaincy or social workers. Although a stay in an ARU is supposed to be a temporary measure, in practice prisoners can be accommodated there for several months (National Health Committee 2010).

In other jurisdictions, these ‘strip cells’ as they are often known, have been widely recognised as unsuitable and inhumane accommodation for suicidal prisoners. Sensory deprivation and the dearth of human contact and meaningful activity are anti-therapeutic and may serve to intensify a sense of hopelessness and increase, rather than relieve, distress and suicidal ideas (HM Chief Inspector of Prisons 1999, Hayes 1995, Wool 1993). In a study on units for prisoners with special needs, one prisoner who had been placed in a strip cell for a month described the impact of this on his mental health:

‘They wouldn’t let me have anything. They even took my glasses off me and it’s horrible, you can’t see nothing…. Even the food was pushed through the door. You didn’t have any choice or nothing.… It makes you feel awful. It doesn’t make you feel better at all(Mills 2003:207).

Prisoners may view strip cells as a form of punishment and be deterred from asking for help for fear of being placed there (Soliday 1985, Liebling 1992, Liebling and Krarup 1993):

‘If you’re contemplating suicide, you dread most the strip cell. It’s not enough to take your pride and dignity away but to take your clothes too, it’s the ultimate’ (Mills 2003:207).

Alternatives to ARUs: Situational and Social Measures

The use of strip cells and other physical suicide prevention methods is often justified with reference to the prisoner’s ‘right to life’ or the ‘duty of care’ of the prison authorities. The Chief Executive of Corrections, for example, has defended the use of physical restraints, stating that prison staff were trying to save the prisoners’ lives in difficult circumstances (Radio NZ 2007a). However, as noted by the Ombudsman, such justifications are based on economic rather than welfare priorities (Radio NZ 2017b). Community and prison mental health practice from other jurisdictions suggests those at risk of suicide and self-harm can be cared for without using methods that amount to torture, sensory deprivation or inhumane and degrading treatment.

In the early 2000s the Prison Service in England and Wales abolished the use of strip or isolation cells for suicidal prisoners (HM Prison Service 2001). It was feared their use was likely to be challenged under Article 3 of the European Convention of Human Rights, which protects the right to freedom from torture or inhuman or degrading treatment or punishment (Levenson 2000, Cheney et al. 2001). Prisons in England and Wales now use a variety of situational alternatives including gated cells and rooms with 24-hour camera observation. However, these measures remain problematic due to a lack of privacy, continuing isolation and the dearth of active, supportive contact offered to prisoners by those observing them (Stubbs and Durcan 2016). They are also highly intensive of staff time which can be costly and lead to a restricted regime elsewhere in the prison due to the consequent staffing pressures.

Academic research strongly supports the need for more social and community approaches to suicide and self-harm prevention to help prisoners to cope with the pains of imprisonment (Liebling 1992, Liebling and Krarup 1993). Where possible shared accommodation on normal prison wings should be used to reduce isolation and facilitate participation in prison activities (HM Chief Inspector of Prisons 1999). Prisons in England and Wales now have ‘safer cells’ which are free of ligature points and are often located on mainstream prison wings.  ‘Listener suites’ are also used. Here prisoners who are vulnerable to suicide and self-harm can be accommodated together with Listeners: peer supporters who are specially selected, trained and supported by local Samaritans branches. They are held in high regard by fellow prisoners (Stubbs and Durcan 2016).

Samaritans Listener

In the late 1990s/early 2000s, a small number of prisons in England and Wales also ran units to help those with special needs, including those with mental health difficulties and addiction issues, cope with life in prison. The units operated as an alternative to mainstream prison wings and other locations such as prison healthcare centres, protective segregation or punishment cells (where prisoners with coping difficulties might otherwise be placed and which could intensify pains due to their restrictive regime and the lack of contact with other prisoners) (Adams 1986, Gunn et al. 1991, Lockwood 1992, Medlicott 2001).

Although the units did not provide substantial psychological therapies, their staff-to-prisoner ratio was higher than elsewhere in the prisons, and staff recognised the need to understand prisoners’ complex problems and be tolerant of their behaviour rather than resorting to disciplinary responses (Mills 2003). Staff encouraged prisoners to talk to them about their concerns in the hope of alleviating their distress. Such talk has been described as an ‘invaluable aspect of care’ (Medlicott 2001:209) and was highly valued by the prisoners:

‘I’m able to cope here, whereas before I was desperately suicidal. This place has helped me cope 200 per cent. I’ve not felt suicidal since I’ve been here. I feel that I can go to anyone on this wing, staff or inmate and support will be there. They’d have a conversation with you, ask you what’s wrong, why you’re feeling that way and just generally take an interest. Treat you like a person rather than an object who should be shut away for his own protection’ (Mills 2003: 209).

Such units operated as ‘niches’ (Seymour 1992) or ameliorative subsettings which reduced the unpredictability of the prison world, and offered an escape from violence. Some ARU prisoners in New Zealand are not suicidal, but are struggling to cope with imprisonment for the first time and feel unsafe on normal prison wings (Ombudsman 2017). These units would also provide a suitable alternative for this subgroup of prisoners, obviating the need to send them to protective segregation.

Conclusion

Prison is generally acknowledged to be a wholly unsuitable place for people with mental health problems. Unfortunately due to the lack of secure psychiatric places in the community and their tight eligibility criteria, prisoners with mental health problems are currently unlikely to be cared for elsewhere.

Prison healthcare in New Zealand is predicated on the principle of equivalence and should be ‘reasonably equivalent to the standard of healthcare available to the general public’ (Corrections Act 2004: Section 75). Seclusion and strip cells are not used in the community for those at risk of self-harming behaviour, so should therefore not be used in New Zealand prisons.

A variety of ways exist to care and support prisoners who are vulnerable to suicide and self-harm if sufficient resources, including staff time, are made available. Corrections is currently undertaking a review of the management of at risk prisoners. This should recommend the immediate abolition of ARUs and the adoption of new more humane ways of preventing suicide in prisons.

Alice Mills is a Senior Lecturer in Criminology at the University of Auckland. She has authored a number of publications on mental health in prisons and ran peer Listeners schemes for the Samaritans in several UK prisons.

References

Adams, K. (1986) ‘The Disciplinary Experiences of Mentally Disordered Inmates’, Criminal Justice and Behaviour. 13: 297-316.

Cheney, D., Dickson,L., Skilbeck, R., Uglow, S. and Fitzpatrick (2001) Criminal Justice and the Human Rights Act 1998. London: Jordans.

Gunn, J., Maden, T. and Swinton, M. (1991) Mentally Disordered Prisoners. London: Home Office

Hayes, LM. (1995) ‘Prison suicide: An overview and a guide to prevention’, The Prison Journal. 75(4): 431-456.

HM Chief Inspector of Prisons (1999) Suicide is Everyone’s Concern: A Thematic Review by HM Chief Inspector of Prisons for England and Wales. London: Home Office.

HM Prison Service (2001) Prevention of Suicide and Self-Harm in the Prison Service. London: Prison Service.

Levenson, J. (2000) A Hard Act to Follow: Prisons and the Human Rights Act. London: Prison Reform Trust.

Liebling, A. (1992) Suicides in Prison. London: Routledge.

Liebling, A. and Krarup, H. (1993) Suicide Attempts and Self-Injury in Male Prisons. London: Home Office.

Lockwood, D. (1992) ‘Living in Protection’, in H. Toch (ed.) Living in Prison: The Ecology of Survival. Washington DC: The American Psychological Association, pp. 267-288.

McCulloch, C. (2017) Corrections breached torture conventions- Ombudsman, Radio NZ, 1st March 2017.

Medlicott, D. (2001) Surviving the Prison Place: Narratives of Suicidal Prisoners. Aldershot: Ashgate.

Mills, A. (2003) Coping, Vulnerability and Disruption: Facilities for Prisoners with Special Needs, unpublished PhD thesis, Cardiff University, UK.

National Health Committee (2010) Health In Justice: Kia Piki te Ora, Kia Tika! -Improving the health of prisoners and their families and whānau: He whakapiki i te ora o ngā mauhere me ō rātou whānau. Wellington: Ministry of Health.

Office of the Ombudsman (2017) A Question of Restraint. Wellington: Office of the Ombudsman. 

Radio NZ (2017a) ‘Very extreme’ prisoner restrained to save life – Corrections, Radio NZ, 2nd March 2017.

Radio NZ (2017b) Tying down prisoner an economic decision, Radio NZ, 3rd March 2017.

Seymour, J. (1992) ‘Niches in Prison’ in H. Toch (ed.) Living in Prison: The Ecology of Survival. Washington DC: The American Psychological Association, pp. 235-266.

Soliday, S. (1985) ‘A comparison between patient and staff attitudes towards seclusion’, Journal of Nervous Mental Disorders. 175: 282-6

Stanley, E. (2017) Torture as ‘Risk Prevention’, Criminology Collective, 6th March 2017.

Stubbs, J. and Durcan, G. (2016) Preventing Prison Suicide: Perspectives from the Inside. London: Centre for Mental Health/Howard League for Penal Reform.

Wool, R. (1993) The Use of Seclusion in Health Care Centres. London: Home Office.

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