Young Offenders in Prison – perceptions of mental health disorders and their treatment: a qualitative study by Helen Cowie, UK Observatory, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK, Nicky Hutson, UK Observatory, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK, Carrie Anne Myers , Department of Sociology, City University, London, UK Theme : International Journal on Violence and School, n°4, December 2007

Aim To explore the understanding of young offenders about the mental health issues that affect them whilst incarcerated, and what support they require. Background The mental health needs of young people in prison continue to pose a serious health problem for the individuals concerned and for society as a whole. Violent behaviour, towards others and towards the self, remains a disturbing problem. This study addresses the issue from the perspective of the young people themselves through interviews with young offenders currently serving custodial sentences. Method Qualitative interview study with thematic analysis. Setting Twenty in-depth interviews with young people (10 males and 10 females) in 2 Young Offenders Institutions. Participants 16-20 year old young offenders, completing sentences in Young Offender Institutions in England. Results Awareness of a range of mental health issues existed among all of the participants. At the same time, there was widespread prejudice towards those with mental health difficulties despite personal experiences of difficulty and day-to-day observation of peers in distress. Participants appreciated the information and treatment that they received on drugs, alcohol and substance abuse but felt that this input took place at the expense of treating other mental health difficulties. They reported over-use of medication, some inappropriate prescribing practices and a dearth of therapeutic interventions such as counselling. They reported suspicion of in-house support because of the lack of trust inherent in the prison environment. Conclusion Young people in custody are a particularly vulnerable group with a strong need for appropriate information about mental health issues and the provision of counselling and other forms of social support to alleviate their distress. Nursing and counselling staff in prisons potentially play a critical role in addressing this urgent issue by focussing on the emotional and educational needs of young offenders. Nurses currently tend to fulfil a medical role in prisons, prescribing medication, but additional counselling based training seems an appropriate way forward so that nurses are empowered to address their mental health issues in a holistic way. English text.

Keywords : young offenders, mental health, violent behaviour, self harm, children’s rights, counselling.

PDF file here. Click on the title for see the text. Introduction Young offender institutions are run by the Prison Service, and usually house boys aged from18-20 years. Female offenders are housed in self-contained girls’ units attached to existing female institutions. On 3rd November 2006 there were 11,862 under 21 year olds in prison in England and Wales (Prison Reform Trust 2006). In the last 10 years, the number of sentenced young adults entering prison has increased by 21%, and the number of sentenced young women has doubled in the same timeframe. For many, a prison sentence is one of a myriad of problems that they have already faced in their young lives. The majority enter prison with existent housing and employment problems, with nearly two thirds (63%) being unemployed at the time of arrest; the Chief Inspector of Prisons also estimated that one in five young prisoners had no idea where they would live on release (Prison Reform Trust 2006). The social experiences of young offenders reveal that almost all of them have endured various kinds of abuse and deprivation (Carlile Enquiry, 2006; Graham & Bowling, 1995; Utting, Bright & Henricson, 1993). Neglect and family conflict, poor domestic care, and the absence of a good relationship with either parent have all been shown to increase the risk of behaviour problems and subsequent juvenile offending (Farrington, 1995; Yoshikawa, 1994). Young offenders have significant risk factors for mental health difficulties. The Prison Reform Trust (2006) found that the rates of all mental disorders (psychosis, depression, posttraumatic stress disorder, substance misuse) are substantially higher in young offenders than in young people in the community. This is to be expected as so many of them have experienced events in their lives that are known to increase the risk of mental disorder. These risk factors include inconsistent and erratic parenting, over-harsh discipline, hyperactivity as a child and additional family stressors. Over one-third have been ‘looked after’ children in Local Authority care. The levels of previous physical, sexual and emotional abuse, school exclusion, low educational achievement and unemployment are all high and many are teenage parents. They are more likely than adult prisoners to suffer from mental health problems, and are more likely to commit or attempt suicide than both younger and older prisoners. Various aspects of risky behaviour such as offending may in themselves cause mental health problems (Mental Health Foundation, 2002). Being incarcerated causes extreme stress and anxiety, sometimes due to fear of bullying and violence within prison itself (Ireland & Monaghan, 2006). Furthermore, research has suggested that the detection of mental health problems in the young offender population is imprecise, and tends towards underestimation (Carlile, 2006, Mental Health Foundation, 2002). Despite the extent of mental health difficulties being experienced by young people in custody, Carlile (2006) expressed grave concern that their access to treatment and protection, during and after detention, was less than that offered to children in society at large. This contravenes their rights according to the Children Act 2004, and the UN Convention for the Rights of the Child (UN, 1991). Together, these pieces of legislation dictate that children should be consulted in matters that affect them, yet rarely are young offenders given a voice on their own mental health issues, and the provision they would like to help them. The role of prison health services Since 2003 there have been some improvements in the UK in the availability of healthcare services for young offenders (Health Care Commission, 2006). Over 80% of health workers now report good access to Child and Adolescent Mental Health Services (CAMHS) for advice and support, and an increasing proportion of health workers in Youth Offending Teams (YOTs) (the multi-agency groups that bring together experts in education, health and social care) have a mental health background. Most notably, a high number (90%) of YOTs report good access to a substance misuse expert and substance misuse services. Following the UK government’s modernisation agenda, prison mental health in-reach collaborative care teams are being established to improve the quality of care for prisoners who need it and to help provide appropriately trained and skilled staff to deliver this care and to help prisoners through the process of returning to community living (Emslie, Coffey, Duggan, Bradshaw, Mitchell & Rogers 2005). Furthermore, the National Prison Mental Health Work Programme is now fully established through NIMHE (National Institute for Mental Health in England) and has eight prioritised areas including women’s mental health issues, suicide prevention, developing in-reach teams, and appointing additional staff to work in prisons and support a mental health care plan. However, despite these various initiatives, the inspectors in the Health Care Commission found large areas where there is still an urgent need for improvement. On the basis of their review of 50 out of 155 YOTs in England and Wales (since the review there are now 157 YOTs), they confirmed that too many young offenders have insufficient access to mental health care. For example, 1 in 6 YOTs did not have a healthcare worker even though primary care trusts have a statutory duty to provide one, and one third of YOTs did not have a mental health worker even though 40% of child and young offenders have emotional or mental health needs. In addition 60% of YOTs did not have adequate involvement by a healthcare professional at strategic/board level; the work of healthcare professionals did not always reflect the health needs of the young people; one in three YOTs had no formal protocols for holding the NHS to account for their services; 16-17 year olds were especially disadvantaged by the provision of CAMHS with a clear gap in services for this age group. The mental health services provided to young people in custody are generally inadequate (Prison Reform Trust, 2006) in comparison to the adolescent population as a whole, despite their increased risk (Youth Justice Board, 2005). There is growing concern about this lack of provision for a particularly vulnerable group of young people. For example, in response to the Chief Inspector of Prisons’ report into Feltham Young Offenders Institution, the Chief Executive of the Sainsbury Centre for Mental Health (Greatley 2005) argued that the lack of appropriate treatment and support for people with mental health problems in prison is ‘a national scandal’ and indicated that this particular YOI was not alone in being unable to cope with the mental health needs of its inmates. Consulting with the client group In the UK, providers of mental health services now have a commitment to involve the service users. The implementation of the Patient and Public Involvement Agenda is being extended to prisons across South West England, despite difficulties arising from security restrictions (Emslie et al 2005). A key issue for young people in general and for young offenders in particular lies in lack of knowledge about mental health or how mental health issues might be addressed (Bailey, 1999, Gelder, 2001, Kendell, 2001). Coffey (2006), in a literature review of research into service user views in forensic mental health, found that the volume and breadth of such studies was limited and that many of the studies were flawed in terms of the conduct, application and reporting of the research process, and with an absence of discussion of ethical issues involved in carrying out research with such a (literally) captive group. In line with Bartlett and Canvin (2003), he makes a strong recommendation that we also need to be more radical in involving the recipients of care in designing, conducting and writing their own research so that their views are more accurately represented. In the context of the present study, this is an especially salient point. The study Aim The aim of this study was to explore the accounts of young offenders in order to identify their understanding of, and attitudes towards, mental health difficulties, and to elicit from them how young people with mental health issues would like to be supported in prison. A qualitative approach was adopted in order to maximise the chances of capturing the voice of the young offender. It was emphasised at the beginning of the interviews that they did not have to report their own mental health issues unless they wanted to. Method Interviews with Young Offenders After gaining ethical approval from the Prison Service Ethics Committees in each institution, interviews were conducted in two Young Offender Institutions in England. The female institution, at the time of interview, housed 184 female offenders. The male institution housed 360 detainees in the same timeframe. Aware of the particular ethical issues involved in carrying out research on prisoners, as discussed in Adshead and Brown (2003), the researchers fulfilled the process of consent criteria recommended by Rothwell and Smith (2003). They took care to explain the context in which the research took place. Participation in the project was voluntary and each young person was told in the consent form that they could withdraw at any point during the research process. In line with Coffey’s (2006) recommendations, we felt it important to involve the young people as co-researchers in the project. To this end, each participant was informed that the research was part of a wider project linked to the Anti-Stigma Campaign and that one of the outcomes would be a DVD designed specifically to help young people in prison deal with emotional health issues, and that it was an initiative in which they could play an active role from start to finish. All participants were invited to take part in both the research process, and the filming if they wished. Young offenders were also involved in the final editing and evaluation of the DVD. The sampling technique employed was convenience sampling. In other words, the research programme was advertised within the prison, and participants volunteered to take part. This technique obviously has some shortcomings. Does the research lack validity as a result, and were the individuals that volunteered both qualitatively and quantitatively different from those that did not volunteer with regard to their mental health needs? We were assured by the prison staff who knew the respondents that our volunteers did represent a cross-section of the prison community, and unfortunately, we had no choice but to believe this. Ten women volunteered immediately to take part. However, we did have concerns with the 10 male volunteers. On the advice of the prison staff, the young men were offered a small sum of money to take part. By contrast, the prison staff did not consider that a financial incentive was necessary for the young women. (Adshead and Brown (2003) give a useful discussion on the contentious issues that face researchers who offer a financial reward to prisoner participants). In the event, the young women were extremely enthusiastic about taking part in both audio-taped interviews (for the present research) and filmed interviews (for the DVD). The young men were much less forthcoming and appeared to be motivated more by the money than by the wish to take part in the project. Each of the 20 volunteers was issued with written information about the study before they agreed to take part. Interviews were carried out by two female members of the research team (NH and CM) who were not previously known to the participants. At the beginning of the interview, the researchers verbally explained the details of the research study, before asking for written informed consent from each participant. This was to protect both the researchers and the inmates. We also asked permission to tape record the interviews before proceeding. Each interview took approximately 45 minutes, and followed a semi-structured format. The young people were informed that they could stop the interview at any time. Complete confidentiality was guaranteed with regard to the interviews. Furthermore, the interviewers did not ask the prisoners or the staff why they were serving a custodial sentence. This information was one of the terms of conducting the research, as we were not concerned with why they were there, but rather, how their experience of incarceration impacted on their understanding of mental health issues of young offenders. Subject areas covered included an overview of what they thought mental health was, attitudes, beliefs and knowledge about mental health, and how they felt young offenders’ mental health needs could best be supported. Analysis The analysis was a four stage process involving thorough thematic content analysis techniques adapted from Glaser and Strauss’s (1967) ‘grounded theory approach’. The various stages used are outlined below. Full Transcription: Firstly, all interviews were digitally recorded and fully transcribed by the interviewers. This proved a useful exercise as it allowed us to embed ourselves more deeply in the data by listening to the nuances and hidden messages within the research. The initial transcription process was also integrated with field notes taken by the interviewers during the interview which we used to draw attention to themes and items of particular emphasis and interest (this technique is drawn from Field and Morse 1989 ‘memos’ method for categorising data). Producing an exhaustive categories list: The transcripts were then re-examined in conjunction with the fieldwork notes. An exhaustive category list was devised providing a systematic record of all the themes that arose during the interviews. This was initially completed by jotting the themes down as they appeared by hand, in the margins of the transcripts. This process was completed separately by both researchers to increase validity of the final code frame, and where possible avoid bias. A neutral third party was also given a transcript and also asked to pull out the relevant themes as they saw them. At this stage, all of the data were accounted for within a category. Collapsing Categories: The next stage of analysis involved collapsing some of the categories down to form broader themes. This stage was again undertaken individually and results were compared until we had a fully agreed upon and coherent list of themes, with categories within them. A computer package NVivo version 2 (QSR International, Melbourne, Australia) was used to streamline this process. Re-interpreting meaning: Once this exercise was complete, the data were re-examined with a copy of the full transcript also present to ensure that the context of what was said was maintained during the remainder of the analysis. The findings reported in this paper represent all the relevant themes that emerged during the research. The thematic analysis that emerged is used throughout this paper to illustrate the findings of the study, with verbatim excerpts used where appropriate. Results The final detailed systematic analysis resulted in a number of themes, including young offenders’ knowledge and understanding of mental health, their attitudes towards people with mental health difficulties, their knowledge about mental health, and their views on how individuals with mental health issues could be supported and helped. We discuss each of these themes in turn, and relate them to the final conclusions of the study. What is Mental Health? Box 1 summarises how participants defined mental health. The majority had an opinion on what it meant to have mental health issues, although some of the young men in particular admitted that they had never thought about it before. Two thirds of respondents indicated an understanding that mental health issues can be internalised, and result in anxiety, depression and self harm, or be externalised through anti-social behaviour. They were also aware of the importance of early family experiences on current mental health. Box 1: Examples of Young offender’s definitions of what mental health is Early Experiences in the family : I believe it comes from when they were a child, I mean something that came from a long time… that happened to them maybe, usually happens in the childhood, I think, from the parents. Maybe they been abused or... they saw a lot of abusing going on in their family, and that’s what brought it all up, so if they seem something similar to that it just hits them. Irrational thoughts When there are certain things in your head that you can’t really get yourself around, like things that get to you and that… issues that get to you and you can’t deal with in yourself… Hereditary Illness Illness, innit, illness. Um, I think it’s special needs, learning difficulties. Um, depression, self-harm…like that really. They’re poorly, ain’t they? I don’t take it to heart but other people just take the piss out of people like that. Myself and my family have got learning difficulties and mental health problems. My aunty’s a schizophrenic and all that and people are like all like that but they can’t help it. That’s just the way they were born. Self Harm and Suicidal Thoughts Or like if somebody’s mentally ill to me, they can’t stop hurting themselves and they wanna be dead or they’re thinking like everyone else is hurting them and out to get them. To me, that’s somebody that’s mentally sick. And they think the whole world’s against them. Attitudes and Stigma As already noted, adolescents in general tend to have negative attitudes towards mental health (Bailey, 1999, Gelder, 2001, Kendell, 2001), and this was confirmed in the present study. Individuals with mental health issues attracted a number of labels from other inmates and these were invariably negative. They ranged from mental fragility to more negative views that revolved around psychotic behaviour and violence. Bad. Like they’ve got something seriously wrong with them. That they’re violent and that you want to keep away from them as you don’t really understand what is going on, and that’s how they’re seen, even though it could be not as drastic as that.. A total of eight detainees reported a fear of individuals with a mental health issue: Um, when people see people and they’re mad, most people are either scared of that person or some people like get at that person… A general label of being somehow ‘different’ from an undisclosed ‘norm’ was common:   Different, as in like they’re not as in like on your level. Seven participants had observed people being bullied because of having mental health difficulties. This was often reported as a lack of understanding toward an individual’s problems: …so they get a crack out of them so that they can laugh at them. Cos people are evil. Some people just don’t leave people alone, they do wanna make a joke out of them. And like trigger off what they know’s gonna make them switch and go on the way they do. Another derogatory attitude towards those with a mental health issue was that it was some form of attention seeking behaviour. There were also accusations of ‘faking it’ as a means of gaining privileges: Well, put it this way, people that have got mental health issues they get a lot more things like… colouring books and that… people that haven’t got mental health issues like myself, like I don’t matter in here, which is the right way really cos I don’t need help but they do put a label on them…. Overall it appeared that mental health issues were not really talked about, and this lack of communication resulted in a lack of understanding: No one really does say that “this person’s got mental health problem” sort of things like that so you don’t really know. It’s just like what I’d think someone is, it’s like someone who cuts up or something like that. It’s not, it’s not really talked about. Knowledge about Mental Health On the whole knowledge about specific aspects of mental health was limited, although regardless of previous experience everyone became ‘knowledgeable’ after spending some time in custody: Yeah, I see it in here every day, man (laughs), everybody, most people are mad in this place I swear. All in different ways but there’s something wrong with them. (laughs) Twelve individuals said that they felt that mental health issues were brought on by the very experience of being in prison: It’s people who have lost it, man. Like they’ve been in here too long. You know, theye’re messed up. The most commonly cited examples of mental health issues within a prison context concerned self harm since everyone interviewed had either self harmed or witnessed self harming: In prison people cutting their arms and stuff like that… I dunno, they don’t treat em very good cos they still give em razors… to keep in their cells. Well, when I used to cut my arms, and when I first come on the wing here and everyone saw it, they’d say ‘I hate people who cut their arms’ . They just don’t understand why people do it… but people who do it understand, and them’s the only people that do understand… What would help? Although the interviewees lacked specific knowledge about mental health issues, this was often regarded as a consequence of a lack of communication about the topic, despite the fact that every young offender institution has a nursing team, a resident psychiatrist, and forensic and clinical psychology staff. They alluded to the need for outside support: I think that they should like get people to speak to people more after cos that way if people are talking about their problems more then they’re not going to be going on the way that they do. In this prison, like people do come round, I’m not saying they don’t but once in a blue moon, you know what I mean? And then when they come round, you don’t feel comfortable speaking to that person, you know what I mean? Participants acknowledged and appreciated the support that they received on drugs, alcohol and substance abuse. However, they felt that this information and treatment was given at the expense of other, equally serious, mental health conditions. At least two thirds indicated that medication would not solve the deep rooted psychological issues that many young offenders had. Poor prescribing habits were also highlighted. For example, some of the young women had requested medication to help them cope with their prison sentence and the medical staff had responded accordingly. However, the young offenders appeared to be confused about such standard information as dosage instructions and reported that they often misued their tablets through ignorance. Another issue that arose was the recognition that some were ‘working the system’, for example, by getting medication under false pretences in an attempt to numb the pain of being in prison. The need for alternative forms of treatment to meet mental health requirements was a commonly cited request. Talking through the issues with a counsellor was seen by many as preferable to being prescribed drugs. Counselling was viewed, especially by those who had engaged in a programme of treatment, as the ‘better’ way to deal with mental health issues. The need for confidential, one-to-one support was constantly referred to. Group work was considered unlikely to succeed since there was a lack of trust amongst the inmates. However, the young person’s values or cultural experiences prior to incarceration played an important role in influencing how they responded to their emotional needs in prison. Many had approached counselling reluctantly, only to appreciate its benefits on completion. There was an overwhelming desire that the people confided in were sympathetic. Inadequacies of support and help were often cited, particularly the limited availability of the psychiatrist. Ultimately, many relied on their own undeveloped coping skills to deal with the day to day issues of prison life. This led to anger, frustration and hopelessness and these emotions were often vented in violent acts, whether towards themselves or others. Overall, mental health was regarded as an issue that required urgent consideration, since the majority felt unable to cope on their own, without adequate support. Discussion Prisoners are vulnerable because of their lack of freedom and lack of personal autonomy. Their voices can easily be undermined by their status as convicted persons and too often their views are dismissed on the basis that they are unreliable witnesses, that they are prone to telling lies and that they are incapable of giving sensible answers to researchers’ questions. In this study, we tried to balance the rigour of scientific research with the need to give a voice to a group of young people that is often ignored on the grounds of being ‘too difficult’ or ‘incoherent’ to be taken seriously (Bartlett and Canvin 2003). This study confirms that there is a lack of knowledge about the nature of mental health issues in Young Offender Institutions. Young people in custody become aware of mental health issues, through their own direct experience of being in prison and their daily contact with peers who have some form of mental health disorder. There was a clear divide between the mental health needs of the young men and women, with self harm being predominantly a female issue, whilst suicide was a male concern. However, every prisoner requested contact with someone from outside the prison, whether this was formal support or more time with their family. Internal support held less value, due to lack of trust between prisoners and members of staff. Many reported that they were receiving medication to alleviate their problems, and whilst some felt this was necessary, others were concerned that their medication masked their problems, and that their issues would be exacerbated on their release from prison. The overuse of medication within the prison environment is likely to create its own set of problems. The participants’ perception of over-prescribing has been confirmed by other studies (Prison Reform Trust, 2006), and is an area that urgently requires further investigation. Nursing in prison is often compared to working as a practice nurse in a GP surgery, but the results of this study confirm that it is often far more challenging than this. The high number of patients with mental health issues and substance and alcohol abuse means there is a significant role for health promotion amongst this client group. There is also a greater need for a more counselling based approach to try and understand the mental health issues that they are facing, which the young people often fail to recognise themselves. However, it must be acknowledged that within the prison environment, nurses face a ‘role conflict’ between their desire to offer more therapeutic care, and their need to ensure that security and their own safety are maintained at all times. The young people acknowledged the helpfulness of drugs and alcohol rehabilitation programmes and these seem to be well-funded and designed. Yet, according to their reports, there is need for greater focus in treating the wider range of mental health difficulties experienced by young people in prison, including aggressive behaviour, stress, eating disorders, self-harm and suicide, and depression. The overwhelming need to communicate their fears and anxieties about their condition to a trusted individual, such as a nurse or a counsellor, is a realistic goal for the future. The young women in particular indicated their willingness to offer support to others in the same situation as themselves through their enthusiasm about the educational potential of the DVD. Against a background of worsening mental health in the adolescent population in general (Collishaw et al, 2004) it seems that (with the exception of drug and alcohol addictions) the mental health needs of young offenders in particular are not being met by existent services. The expertise and resources that the young people themselves request are commonly not provided, and access is limited. It is likely that ignoring these issues will result in worsening mental health problems, increases in self-harm and aggressive behaviour and further offending. Not only does a history of offending make mental health problems more likely, but in turn, mental health problems become a risk factor for continued offending (Mental Health Foundation, 2002). The present study reiterated the need as identified throughout the 5-year Anti-Stigma Campaign to educate people about mental health issues and to provide all at-risk populations with up-to-date information on services available to them. Although the sample was small, there was evidence that the young offenders would appreciate access to confidential counselling and emotional support from sympathetic adults external to the prison service. Confirming Barlett and Canvin’s (2003) perceptions of the need to acknowledge the credibility of the prisoner voice, the participants expressed the value of actually asking those most closely involved in a context (that is, the young offenders themselves) for their views on what would help them the most. The aim of phenomenological research is to offer a glimpse of another person’s perceptual world (Glaser and Strauss 1967), without bias and subjectivity, and this is what we have attempted to do. The young people acknowledged the inroads made by healthcare teams in prisons to deal with drug and alcohol addictions. The findings also support the need for pioneering work involving in-reach collaborative care teams (Emslie et al, 2006) and the recommendations of Lord Carlile. However, there are other pressing mental health needs experienced by this population of young people. We conclude that the counselling and nursing staff in prisons could play a critical role in disseminating up-to-date information about mental health issues and in developing formal and informal systems to provide confidential support to all young offenders at risk of the daily emotional pressures of prison life. Authors’ contribution HC, NH and CM designed, conducted the research and analysed the results. All authors contributed to the writing of the paper. Acknowledgements This research was funded by the Prison Service. We thank the young people who responded to the interviews and the staff in the two Young Offenders Institutions who enabled us to carry out the research. We also thank the anonymous reviewers whose detailed comments guided our revision of this article.

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