It’s very challenging working in prisons. There’s inherent tension in my work as an adolescent forensic psychiatrist – the dual role of caring for the young person while managing their risk to others. It’s the prison and nursing staff who are always standing between us (the doctors) and the patients, the prisoners. Always. It’s easier to take positive risks if you are not on the front line – and yet we know, that when we can be more positive and less punitive with young people, the risk of violence reduces. You have to take your colleagues along; they’re the ones taking the risk. Sometimes I manage it, sometimes I don’t.
At times, there are reasons why young people get locked up. Sometimes prisons and hospitals can seem harsh. I’ve seen prison officers and nurses get assaulted, right in front of me and no one should be assaulted at work. But I’ve also seen young people locked up for what seems to be too long following an incident. The prison staff may say: ‘this person is high risk, they need to be locked away for a while’ but we ask: ‘Can we manage things differently? If you lock them away, they’re likely to get more angry. It’s going to be a problem.’
Prison is punishment-based, but there are also incentive programmes which can be used proactively and innovatively to encourage positive behaviour. It is important that these are young-person centred and reward work over a very short time period. For example, for one young person, we had a system whereby if he behaved safely in the morning, he could get his TV in the afternoon. If that improves their behaviour, the vicious cycle of anger, violence, and poor relationship between young person and staff can be stopped. They can be moved out of segregation in good time.
Staffing is obviously an issue and austerity has made things worse. With more staff, prisoners spend more time out of their cells for education or exercise (to play cards, table tennis and chat with other people on the wing). On well-staffed units that would be every day. But it gets cancelled when there aren’t enough. Low staffing can mean being in your cell for 23 hours a day. The people on the ground don’t have a say about staffing; they have to manage with what they have. But that’s when you get more incidents, more staff injured and off sick. This then makes the cycle continue as there are again fewer staff and more lock up.
When working in prison, the least antagonising we are, the more likely we are to see the young person or have input into their care. We have to pick our battles. There are some heated arguments. In my last post, I used to visit the segregation unit every week, when I was there. I didn’t get involved if there a young person was there one to two weeks and had no mental health issues but I’d raise questions if they were there for longer. Were they an imminent risk? What was the plan towards reintegration?
In the end, we have to make our case softly and with research. We have to show why it’s going to be worse to put a young prisoner into solitary.
Despite its challenges, working in prisons for the NHS has given me one of the best days of my career. Last year, I took two former patients, teenagers, to the Houses of Parliament for a Human Rights Committee hearing. They gave evidence to MPs, about the ups and downs of prison life. They were fantastic. They were an example of the really good successes of working alongside young people while inside the prison service.
You can put your head down, not get involved in these kinds of discussions. Have nothing to do with it. Refuse to work in areas where segregation is used. But where would that leave these young prisoners?
There’s much we doctors can do, while also agreeing with the BMA statement that no child should ever be placed in solitary confinement for the harm that it does.
We can work with our colleagues within the prison to develop reward systems to improve behaviour. The new guidance is helpful too. It adds the weight of medicine to arguments, so we’re not just seen as the fussy ones.
Yes, there a tension, a challenge to our ethics, professional practice, and our relationships with colleagues that is inherent in this work. But it’s one we must manage when we care for these young prisoners and one we must manage as best we can. It’s better to be there as one of the voices for the young people than to exclude ourselves at risk that their voice may get lost again.
We have another role too – to raise their voices across society. Everyone hates offending behaviour. It is easier to lock away the offenders rather than think about our failings as a society. We want to blame perpetrators but perhaps we need to take a closer look at ourselves in society about how we care for our young people. How do they get there? What has happened in their childhood to lead to this behaviour? Why are they criminalised and imprisoned rather than cared for in secure as a victim of their childhood trauma?
Heidi Hales is chair of the Royal College of Psychiatrist’s adolescent forensic psychiatry special interest group
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