REPORT

Immigration Removal Centres in England

A mental health needs analysis

Dr Graham Durcan, Jessica Stubbs and Dr Jed Boardman

Terry 8 (Royal Simpson IRC), Wood

(Department (NHS Weston

14 17 Health), Stella of (Yarl’s Claire England), 9 12

IRCs), Pemberton (NHS Adam Helen London), of Kelly Claire England), (Department Natalie University Meek Rosie Professor England), Heaphy IRC), Deborah England),

and Foundation), Bamber (Helen Katona (Gatwick Galver Sandra (NHS Holloway Tan (NHS Petch Template 34 Hawley Angela England), (Royal Hong wellbeing practice received 24 Office), the IRCs 19 Chris England),

(NHS Watkin

Specification 3 (Home 38 Justice). (NHS Dr Cornelius consultant), health Lewis Gwen London), Chris (Home Office), Checksfield Clare England), of Nichols on mental detention

across in place (NHS (public Vanklaveren of OBE Erica IRC), House (Campsfield Grieve IRC), Elaine University Pickles (Medical Schleicher Description of the IRCs the of Description 35 conclusion and Discussion Recommendations 6 summary Executive Introduction Mental health and detention Methods (NHS Cadden Patricia (Home Office), Gibson Alan (Home Office), (Morton Hall Daykin Helen IRCs), (Heathrow Igodifo Victor Anthony Health), Acknowledgements Contents Contents Theresa England), of Holloway (Dungavel & Dr Hilary Davies Kate Nicholas (Home Office), Gipson Gibbs

11 12 References Appendices 8 9 Challenges 27 and well Good, promising 10 The Commissioning 4 5 6 findings The review 7 Impact Services 1 2 3

Centre for Mental Health REPORT Immigration Removal Centres in England 2 Centre for Mental Health Executive Summary

Between March 2015 and March 2016, over severe reported problems were hallucinations or 30,000 people were held in UK immigration delusions. Most of the detainees we interviewed detention. Many of these people had had experienced some form of trauma in their experienced torture, trauma and oppression in life before detention, e.g. fleeing a country their countries of origin. where they were being persecuted; witnessing

loved ones being killed; experiencing domestic REPORT In response to the Shaw Report (2016) which violence, sex trafficking or female genital highlighted the poor mental wellbeing of people

mutilation; or fleeing a death sentence. They Immigration Removal Centres in England detained in Immigration Removal Centres (IRCs), also highlighted issues of mental health stigma Centre for Mental Health was commissioned by and language barriers in discussing wellbeing. NHS England to conduct a rapid mental health needs analysis of IRCs in England. The resulting Impact of detention on mental wellbeing review aims to support NHS England and the Home Office in planning to meet the wellbeing Detainees and staff both described the impact and mental health needs of people held in IRCs. of detention on people’s wellbeing. The challenges to wellbeing were partly caused To gain a full oversight of mental health needs by loss of liberty, the feeling of staying in a in IRCs, we conducted interviews with staff prison-like regime, and uncertainty about their and detainees, asked managers to complete a future. Additionally, confusion about the legal survey, and conducted observations of each IRC. procedures caused a huge amount of distress to Ten IRCs (or ‘holding facilities’) were included in detainees. the needs analysis. "Being here is reliving my trauma because it Mental health and immigration detention feels like the captivity I experienced when I was a sex slave..." Research into the impact of detention has consistently highlighted that: "Things I've buried deep inside I'm having to • Immigration detention has a negative share and now I'm reliving my past. But I don't impact on mental health feel as if I get any support for this..." • The longer someone spends in detention, "I have never committed a crime and they...left the more negative an impact it has upon me in a police cell" their mental health • Depression, anxiety and post-traumatic Services in IRCs stress disorder are the most common mental The mental health provision across the IRCs we health problems visited varied significantly from centre to centre, A study conducted across four UK IRCs in 2009 from predominantly medication management, found that four out of five detainees met a to varying psychological therapy provision and clinical threshold for depression. emotional wellbeing groups. Especially well- received practice included: Mental wellbeing in IRCs • Psychological interventions (as it was generally recognised that the primary All immigration detainees will face challenges need across the IRC estate was for talking to their wellbeing during their stay. Even if they treatments) do not reach a clinical threshold, the distress they experience is still disabling and even life- • Wellbeing groups threatening. • ‘One contact’ approaches (useful in situations where the length of detention Across the IRCs in our needs analysis, the most stay is unknown) commonly reported problem was depressed mood and anxiety problems, and the most

3

and

and have Where their to a passed not should wellbeing. on dentention and and Liaison meet is important of and manage to not very thereafter. this possible Where IRCs. may are Liaison for and guidance genuinely become to vulnerability they once wellbeing vulnerability teams health in the be reflected should Most services. informed a identified after detention, detainees for of or maintenance This is detainees screening. health detention. to challenges the recognise to immigrants’ on detained information their feelings impact and wellbeing distress. therapies talking for need being many their mental of intervals three-month mental Prison ensure should in courts services Diversion that and wellbeing and, where in IRCs teams health on to concerns raise need to they appropriate, making decision detention the during process. models operating mental and prison services and Diversion teams. health to approach a standardised require IRCs mental a review be offered should detainee Any of and at 30 days than more for been detained care and support away from the IRC without without the IRC from away and support care delay. screening and wellbeing health Mental 1. 2. 3. threshold for a mental health service, it is is it service, health mental a for threshold important mental mental need to services health mental IRC All improvements make psychologically medical on the more focus currently services the despite care, health mental of aspects bulk improvement Opportunities express across need expansion Recommendations marked with People be subject detention. be identified before should vulnerability appropriate with be provided should detainee Whilst

risk of certainty and to notice) and staff Home no vulnerability

vulnerability vulnerable

a (often due to short have as and treated understand to

And some staff. at taking population, the exacerbate stay. detainees They

by withheld of type services, (IAPT) disclosed in maintaining also the IRC or had developing were they of immigration with in working formulations groups challenges increases knowledge such detention. seriously taken Therapies

in and frustration. needs by experienced and short culture language, and suicide). self-harm of the centres detect to in place screening challenges if lying were of Access Improving developing for of and religious Psychological the individual of needs and the context teams chaplaincy by offered The support risk they their anxiety Conclusions multiple experienced have detainees Many be all can which of the effect traumas, exacerbated vent to ways limited and have their future over therapeutic relationships when a decision when a decision relationships therapeutic is a detainee ‘remove’ to Enforcement Immigration Office that perception of ethical continuity ensuring including detainees, for and even ‘removed’ being those for care (always released being those but the community; to security or care either heath to to easy was it reported that members staff disbelieved which a culture part of become detainees. a number of face staff care health Mental clinical an individual. detain to deciding before not were they that perceived detainees Most not to, listened if of range A wide difficulties NHS from desire an expressed Despite in IRCs. that and the Home Office England no is there be detained, not should people These services will need to be adapted to meet meet to adapted be to need will services These the specific account durations unpredictable Challenges Most plans Psychological in the community. available those to similar • •

Centre for Mental Health REPORT Immigration Removal Centres in England 4 Centre for Mental Health Mental health and wellbeing support 3. All IRCs should have access to mental health practitioners who solely have mental health 1. All IRC mental health services should have related duties. This means that one or more a wellbeing focus and deliver the stepped staff as appropriate has a dedicated mental care model. All commissioners need to health function that is not secondary to a rigorously ensure that services reflect the general health function for daytime shifts, stepped care model and that there is an seven days a week. appropriate balance between psychological

offers of care and psychiatric and medical REPORT Staff training and development care, with the greatest emphasis placed on the former and clear pathways for those 1. All staff in IRCs should be trained in their Immigration Removal Centres in England requiring specialist care. role within the Stepped care Model, and mental health practitioners should receive 2. Access to alternatives to psychological access to training and clinical updating. intervention such as relaxation therapy should be increased. 2. All mental health care practitioners should be provided with robust clinical supervision 3. IRCs holding women should demonstrate and have access to both peer supervision that they have an appropriate gender- and one to one supervision at least once per specific response that reflects the different month. needs and context of women in detention. Treatment pathways for those experiencing 3. Mental health awareness training should trauma should be specified. be mandatory for all new IRC staff as part of their induction and all staff should have 4. There should be a review of NICE guideline mandatory annual update training. compliance, particularly with regard to the assessment and treatment of trauma. 4. A forum should be created across all IRCs to allow for the sharing of good and evidence 5. We recommend that the availability of time- based practice between practitioners from limited psychological interventions should different institutions. be increased across all establishments. Future Health Needs Assessments at IRCs Continuity of care should be required to provide more specific guidance on the resource required for each 1. IRC health care staff should be given element of the Stepped care Model. maximum possible notice of release to ensure continuity of care for the most 6. Peer support interventions should be vulnerable detainees (i.e. those at risk of developed, including the potential for peer relapse in health if released without an mentoring. active care plan in place). Staffing levels 2. Planning continuity of care and access to appropriate mental health treatment for 1. All IRCs should have access to expertise detainees following their removal (e.g. that can guide appropriate interventions discovering whether their medication is for supporting detainees managing the available in their country of origin) should experience of trauma. be centrally managed within the NHS and 2. All IRCs should have ready access to a not the sole responsibility of individual IRC mental health crisis response 24/7. This health care teams. can either be through having appropriately trained staff at night as well as during the day, or via a responsive on-call service during the night.

5

Shaw

this to 2016, Secretary, of the Professor of review of the term airports, report Shaw The report report Shaw or transfer range a broad Shaw that note to findings uses the mental detainees' the to relating the Home 2016), and Shaw, (Bosworth Centre 2016). Shaw, (recommendations remit. commissioning 5 of 5 of NHS responsibility, in (IRC) estate Centre important this the recommendations at be held also is a systematic from ten However, wellbeing. to report Shaw of of detainees commissioning for responsible removal awaiting England’s may the to a response by conducted literature The specification a service developed part is NHS diagnosable from problems, health findings and the recommendations particularly recommendations, For cells. and prison police and entry, covers which wellbeing’, Appendix health. of is England report in January report, published Shaw 2016). It Shaw, mental includes international of the impact Mary Bosworth, and examines detention of health on the mental detention immigrants. ‘mental of analysis Report. The by been commissioned had 64 recommendations. and made of the poor state highlighted Many wellbeing. indirectly related to directly related the recommendations of of the wellbeing 11,12,13,16, 23, 53, 55, 56, 57 & 58). In 55 suggested recommendation particular, level the of assessment “…a clinical that concerns…” health mental of and nature 197: (page be undertaken This report’s 55. recommendation 9 and Appendix Chapter the concerns to devoted are mental In March 2015 these centres held around around held centres these 2015 In March (Bosworth in 3,500 people into came 32,400 in total year same the over & Hajela, (Silverman detention immigration 2016). Others ports most 2015, 374 people, on 30 March example, were sentence, prison a completed had whom of in prisons held Removal an Immigration to in entry airports ports are and of as such locations of outside NHS the part of in that provision care health all Removal Immigration As England. has England account into take to template

South and Shaw, the took Centres in health health Health apply, also England The analysis IRC of wellbeing in England, and England may Stephen

2017 Home Office, commissioned NHS Dungavel to in England. visit mid-February between mental a rapid providers health to the mental for The Dungavel visited IRCs the NHSE to IRCs to confined of 2016. NHS the Home Office. analysis that assume to reasonable also We April is and recommendations analysis was review conduct to asked by been commissioned 1. Introduction claim needs to be established; and where it is is it where and to be established; claim needs their with comply not a person will that believed conditions.” admission or release temporary Those who are liable to be detained in IRCs in IRCs to be detained liable who are Those to effect detained been who have those include served time the UK including from removal their to subject persons offenders; national foreign of basis or identity whose control immigration that a person can be detained in certain in certain be detained a person can that of immigration purposes the for circumstances will a person that mean not does This control. of a matter as and automatically, be detained against a presumption always is there policy detention. needs health and early Centres Removal Immigration provides legislation immigration “UK-wide speak to Lanarkshire observe practice. separately place work. the mental conducted Health Mental for Centre This though it findings outside the one IRC to in principle, least at England. Ombudsman, and Probation Prison the former vulnerable of the welfare reviewed which highlighted and had in IRCs, held people concerns particular detainees. immigration Removal in Immigration provision care Mental for Centre in England. (IRCs)¹ was needs a report (the to in response commissioned was Report, by 2016) written Shaw Background to the report to Background Health, Mental for Centre report, by written This has supported by all commissioning for responsible are ¹ For the purposes of this report IRCs shall include Residential Short-Term Holding Facilities (STHFs) Facilities Holding Short-Term include Residential shall IRCs report this of the purposes ¹ For

Centre for Mental Health REPORT Immigration Removal Centres in England 6 Centre for Mental Health mental illness to psychological and emotional • Provide a rapid needs analysis; distress that might fall below a clinical • Describe mental health need; threshold. The Shaw report reveals that the • Describe existing provision; manifestation of poor mental wellbeing amongst detainees is typically through symptoms of • Comment on relevant aspects of IRC low mood and depression, anxiety and trauma. regimes; Serious mental illness, such as schizophrenia • Describe gaps in service; and bipolar affective disorders, are less • Make recommendations for improvement common, but both Shaw and Centre for Mental and to address gaps. REPORT Health’s needs analysis encountered people in

IRCs experiencing these problems. Whilst this review was mainly concerned Immigration Removal Centres in England with what happens within IRCs, the review’s Aims of the Mental Health Needs commissioners also asked the reviewers to Analysis comment on relevant issues that did not directly concern IRC regimes. These included the This Centre for Mental Health review is intended assessment of the vulnerability of people before to support NHS England and the Home Office in arrival at an IRC and their continuity of care after achieving Shaw’s Recommendation 55. Centre leaving an IRC. for Mental Health was commissioned to:

7

five study of (2009). study a clinical (n=49). This sample diabetes et al al et (n=30) met men, there poor for factor out four 30 days. fit and population, a negative for trauma. at physical between as such problems. health of UK The single point a risk are immigration including in the study mental in the community illnesses was health of months. and PTSD depression anxiety, study physically young of 175). 2016, page of duration longer with associated the critical that in 2009 found six to part taking (n=67), other detainees are a pilot was IRCs health. on mental was “Those who were more depressed were: were: depressed more who were “Those been longer in detention. They did not use use did not They in detention. longer been services, religious or the gym like activities library or room the IT or staff report did not spent and of detention, aspects positive as likely also more were They time reading. less was detention immigration that to report unjust.” were and problems women, had health the in long lived had not medication, taking to detention, prior in prison been UK, had not and/ times), 2 to (up asylum for had applied who Those review. judicial for had applied or experiences specific had also depressed were likely more were they IRC: particular that in refusal, food in a fluid or participated to have [Assessment on an ACDT placed been to have plan, Teamwork] and in Detention Care to have and interpreters, used to have 18 days report (Shaw conditions term longer mental on the impact focused review the systematic As say to little has it health, on mental detention of of on the prevalence across conducted study a separate However, UK four detainees (Bosworth and Kellezi, depression for threshold 2015). most studies have found the critical point to to point the critical found have studies most a range with in detention earlier much come of Robjant by conducted that is cited This detainees seekers and asylum Higher levels immigrant in the detained found were and this and/or a history detention that showed impact the link Bosworth made also most and whilst health and mental health detainees higher levels are population in the detainee and tuberculosis the general to when compared

the

of

of that found upon the from findings health has it in detention, by believed are the than harsher a negative longer are health immigration for She reports some of reason However, review. Appendix 2016, Shaw the findings on mental sizes The sample or physical health health. studies: the UK. to poor mental months; however, be 24 to health. of trauma, pre-existing detention, 700. Most 10 to from ranged provision. care and poor health detention. after long Australian. were problems. health on mental is regime detention point studies Australian from mainland. Australian reaching from in the UK uncommon international are there However, their detention. before summarises section group. impact The negative persists of duration mental pre-existing problems torture of victims for are outcomes worst The vulnerable a particularly are and women their mental and post-traumatic anxiety Depression, common the most are disorder stress mental The causes has detention Immigration impact someone spends The longer an impact negative the more not study be observed. One Australian is 2. Mental health and detention health 2. Mental in Bosworth's emphasised be the to found have they in what vary studies health in mental a decline such which at point will the critical • association and its detention of The duration are outcomes health mental poorer with • • • across • • detention and detention has been outsourced to to outsourced been has and detention detention this For contractors. private findings Bosworth apply to Bosworth reported some consistent seekers It many for in the UK resided have to detainees years and the UK Australia between some similarities of on the duration limit no upper is there in that Japan. and France USA, studies these the studies Australia's asylum prevent to operates and primarily UK systematic review of the literature conducted by by conducted the literature of review systematic Bosworth (see Professor 5). Bosworth identified some 30 clinical Professor the Canada, the UK, Australia, from studies, This

Centre for Mental Health REPORT Immigration Removal Centres in England 8 Centre for Mental Health 3. Methods

The needs analysis employed a mixed methods The interviews served a number of different approach and the individual elements are purposes, in particular: described below. • Informing and refining the needs assessment itself (i.e. method); Using the literature to inform the review • Providing qualitative evidence of needs and REPORT We did not intend to repeat the work of provision; Professor Bosworth, but rather use it to • Making and shaping recommendations that Immigration Removal Centres in England inform the review. It provided some useful fit the IRC setting. ‘benchmarks’; for example, looking at whether there are systems in place in all IRCs for Review of existing data sources reviewing the mental wellbeing of detainees held for longer periods. The IRC estate has This consisted of analysis of data already never undergone an exhaustive prevalence collected within IRCs, where these exist. study such as that conducted in the English and Welsh prison estate in the mid to late 1990’s Collection data on the population (Singleton et al , 1998). Singleton et al ’s study Centre for Mental Health developed a survey adopted a methodology similar to that of the UK tool and issued this via email to all health care National Survey of Psychiatric Morbidity (see managers in each of the IRCs visited. The survey McManus et al , 2009) designed to establish tool is given in the appendices. The survey the prevalence of mental health conditions in provided a snapshot based on 30 March 2016 the community. We have used the findings from and sought details for all those detained on that Professor Bosworth’s review as a guide to likely day on length of stay, placement prior to the IRC prevalence in the IRCs. Professor Bosworth’s (e.g. community, prison), numbers assessed findings are summarised in the previous under Rule 35 (parts 1, 2 and 3), and also the chapter. current waiting time for Rule 35 assessment, numbers on mental health caseloads, those Interviews with key stakeholders and staff awaiting transfer or assessment for transfer Interviews were conducted with stakeholders under the Mental Health Act, waiting times (from and staff over the course of the review. The the point of referral), and for the previous 12 interviews were qualitative and semi-structured months the number of those transferred. and followed a topic guide (see appendices). This data provided vital information of the The topic guide was developed based on context in which health care and mental health the literature and conversations with our care is provided in IRCs. commissioners. The topic guides were refined after the first few interviews were conducted. Collecting data on provision Two Centre for Mental Health staff conducted all the interviews. Those interviewed included: Data on mental health provision was sought • Managers and staff in IRCs; from the IRCs and health care providers within the IRCs. This included all relevant health • Managers and staff with health care roles in services, psychological interventions and IRCs; counselling and other sources of provision • Expert practitioners with experience of IRC (such as those provided by NGOs). In all cases and related settings; this data was collected through interviews • Those with a policy role for IRCs; with health care managers and lead mental • Some key stakeholders from NGOs. health staff on visits to the IRCs. There is also some additional information on newly contracted services by the local NHS England commissioner.

9

also of

the in

were This of visits The 32 detainees The treated were staff Health detail also of managers staff, detainees on gaps a followed Heathrow. their mental being with provision to visit views a group.

Gatwick included: at in an IRC; detention needs wellbeing number of and reviews. on supporting wellbeing. managers, care health and this detained; being prior to as perceived the interviews. units. ('segregation') Separation units; care the health facilities the IRC, including Mental for Centre Two though interview, one-to-one via about: questioned were the target but (see appendices), example, for health; to relating they interviewed. Most were the target) that and challenges service IRC. each of A tour of A tour and employment, activity detainee for and the services and welfare chaplaincy and Care care health interview with A fact-finding and/or mental that to information similar seeking survey care health and mental care health of need, health on mental views provision, 35 assessments, Rule of Their experience Their wellbeing; Their lives What needs; wellbeing mental these How met; being health and mental on health views Their services; care Their thoughts IRCs the two before, at and likewise one unit, Observation of process and practice and of process Observation the visited Health Mental for Centre viewed and 2-3 times between establishments processes consultations health relevant with speaking included initial Each and residents. format standard • • • all conducted As as meant be 50. A total interviewed would (64% of were these interviewed as some were individuals • • • • • • • completed.

to

this

The not of from were were in the use use, to symptoms, mental Health Scale the 12 items diagnostic had These as treated were a 3 for present', and easy Mental measure a routine 1 ‘no problem’, 0 for on clinical interviews few as so Heathrow, The interviews Gatwick who worked staff, health short at of the range is in NHS definitely of comprised The sample practitioners health as used that asked Health focuses visited.

the purposes For IRC. each and the literature reviewing by completed scale, a 12 item the Nation Outcome 48. deploy. to or no training little a ‘severe or 4 for problem’ severe of Each and activities. at is after the first widely as be rated can largely outcomes 15-20 for rating (HoNOS) Scale The HoNOS the IRCs and were guide (see appendices) in a possible resulting problem’, severe both sites. of score very measures. unfamiliar need. patient across be used can a topic by developed some with commissioners, with conversations refinement Interviews and groups with detainees groups and Interviews interview to 10 detainees attempted We of each and semi-structured. qualitative familiar to most mental health practitioners practitioners health mental most to familiar and requires resourced not was analysis needs health mental provide or to interviews clinical full conduct to mental to training of to total It severity for a proxy and provides conditions of skills living on HoNOS a no action’, 2 for requiring problem a ‘mild for but ‘minor problem ‘moderately of The Health is (HoNOS) of It Services. that staff, daily on relationships, items have does but at and likewise one unit, the mental overburden across mental by been assessed who had individuals staff. care health Mental for Centre the Nation of a Health completed staff health Outcome individuals IRCs the two exercise Assessment of need within a sample of people of people sample within a need of Assessment health in mental enrolled and in IRCs detained provision

Centre for Mental Health REPORT Immigration Removal Centres in England 10 Centre for Mental Health Most visits were conducted by a single member that the IRCs visited can hold up to 2,654 of Centre for Mental Health needs analysis team. individuals (and most held close to maximum However, the first visit to the Heathrow estate capacity). The interviews aimed to gain insight was conducted by both members of the team to and understanding of detainee experience, ensure consistency of approach. seeking to include a diverse sample in terms of age, ethnicity, gender and reason for detention. Limitations of the methodology used However, the small sample size does create challenges for generalising the findings. At in the review REPORT best, the interviews give a “flavour” of detainee We were commissioned to provide a rapid experience but this may not be the complete analysis and this posed challenges both for picture. To address this limitation, we have Immigration Removal Centres in England Centre for Mental Health and for the health and employed a mixed methodology, increasing mental health services within the IRCs. These confidence in findings if they are triangulated are small teams and our review added to the (where different methods of data collection competing demands made of them. result in similar findings). The detainees we spoke to and those we There is a significant amount of missing data received ratings on were chosen for us by health in the surveys completed for the review at each and mental health care staff and we cannot be centre. This means we have not been able to sure how representative their views are, and report some of the details of the mental health if we have therefore missed some important services. In both the survey data and clinical views or picture of need. However, across those assessment tool (HoNOS) there is significant IRCs we visited, and those detained therein variability across centres. This may be due to who we spoke to, there was consistency in what genuine variance in the wellbeing of detainees was being reported. Several interviews were across centres. However, it may also be due to conducted with non-proficient English speakers variance in the way problems are interpreted using available translation services, though one and reported. For example, the “problems with attempt to speak with a non-English speaker at living conditions” item on HoNOS was recorded Yarl’s Wood was aborted due to the translation as either ‘no problem’ or a ‘mild problem’, which telephone equipment not being available at the conflicted with detainee views who saw their time. detention and therefore their ‘living conditions’ as being a major problem and one (combined The target for interviews with detainees was with the uncertainty of their detention) that relatively small (n=50) as was the number of affected their mental wellbeing. interviews actually achieved (n=32), given

11

of others also that the to risk turning recent Yet creates (see movement, very (see wellbeing IRCs a receiving a from come of be turnover, capacity, indicates clearly in the lived have level regards With personnel. This a such make also can Some may national foreign study based on the survey based of an overview UK IRC each within population the significant a month and all than some may sources; stay of prisoners. be former the only illustrates month. each population within based services care on health pressures is there However, establishments. these a significant the period and over this of in excess stays have that in mental deterioration increased 7). chapter in IRCs detained who are People number of a period via come and have in the UK arrivals custody. in police or police by and been detained community Enforcement Immigration may any group, latter considered is or more 12 months of sentence and courts removal, for sentencing. when recommendation 1 gives Figure and men or women holds whether the IRC lengths overleaf). It detainees number of a considerable with less staying their static than, or more of, the equivalent over

a House, in Heathrow in

at category to

in included of the site Airport Airport built Campsfield

was prison. of

in Oxfordshire Facility Holding Term

Colnbrook) Gatwick 600, is Gatwick that at and of at Short in Bedfordshire of (comprising than in Dorset For and design. regime in size, and women's vary

on what the day, IRC House regime IRC Wood IRC House

IRC Verne Tinsley Sussex IRCs Heathrow Harmondsworth Airport in London Morton Hall IRC in Lincolnshire IRC Morton Hall Yarl’s IRC House Campsfield Brook Sussex The House Pennine Manchester in Greater 4. Description of the IRCs of 4. Description which holds a maximum of 282 detainees, detainees, 282 of a maximum holds which the centre around move to range free who have throughout Borstal former The centres has built, purpose Harmondsworth is example, capacity a maximum a more and has standards security B prison restricted • • • • • • are: the review • • centres IRCs/holding The English

Centre for Mental Health REPORT Immigration Removal Centres in England 12 Centre for Mental Health

Figure 1: Overview of the IRCs

Max. number Turnover per Gender Length of stay: number of detainees of detainees* month** residing at centre on 3/3/16 in weeks/ months: 12 6-11 2-5 1 mth 2 wks or mths mths mths less REPORT Percentages rounded to total 100%

Gatwick Immigration Removal Centres in England Brook House 448 (322 on 750-1000 Men 3 31 151 119 18 census day) (Gatwick (1%) (9.5%) (47%) (37%) (6.5%) estate) Tinsley 119 (plus 34 Data not provided House family beds) Cedars 3 (now 2) Families Data not provided families Heathrow 1,067 (934 No data on No 39 470 196 229 (data on census Heathrow data (4%) (50%) (21%) (25%) provided on whole estate day) estate rather than by its two IRCs) Harmonds- 676 Men Data provided for whole of Heathrow worth estate (see above) Colnbrook 391 Majority Data provided for whole of Heathrow men estate (see above) Morton Hall 392 (302 on 340-360 Men ***6 ***21 ***47 ***95 ***133 census day) (2%) (7%) (16%) (31%) (44%) Yarl's Wood 410 450-550 Majority Data not provided women Campsfield 282 (256 on 300 Men 0 4 34 88 130 House census day) (0%) (2%) (13%) (34%) (51%) The Verne 580 average 467 (new) 468 Men 1% 2% 10% 36% 51% (discharged) Pennine 32 (HMIP No data on 75% 0% 0% 0% 0% 100% House 2016) turnover, but (HMIP a week stays tend to 2016) or less be for less (HMIP than a week 2016)

The above data was provided/coordinated by health care managers

*: this is capacity and though some were close to capacity, none of the IRCs were full. Yarl’s Wood was in quarantine throughout the review and was not taking new admissions.

**: these are based on estimates given on the first visit, each IRC has been asked to confirm and this is outstanding.

***: Morton Hall data refers to the 7 days before 8/4/16 as this was the data they had available.

13

one

least 11 Wood, – 3

Yarl’s

or delusions; 0 0 0 0 7 19.85 Yarl's Wood Yarl's 20 Female 35.5 (20-62) 1 Average month (2 days months) 5 15 Gatwick Yarl’s

at having reported problems of on the wellbeing self-injury; 0 0 0 0 3 4.4 Heathrow 5 Male 36 (25-52) 1.5 Average (3 months weeks-3 months) 0 5 impact commonly At or delusions”. At or delusions. hallucinations with mood; depressed with relationships. with At mood”. “depressed reported as were Non-accidental problems; Cognitive Problems Problems Problems or disruptive aggressive, Overactive, behaviour; agitated to relating problem a moderate having 0 0 0 4 3 2.1 Campsfield Campsfield House 10 Male 31.9 (19-43) Average 2 under just (1-4 months months) 3 3 • • • • • a significant had detained. those reported commonly the most IRCs, Across was problem the most Wood “non- mood were depressed alongside and self-injury”, “other mental accidental problems” “relationship problems”, behavioural conditions”. and “living severe most the centres, other all Across with “problems reported was problem hallucinations reported was one individual and Heathrow, as hallucinations individuals items: the following to relating problem severe •

the

in – 10 each

four higher 1 1 1 3 4 2.1 Gatwick Gatwick House) (Brook 20 Male 32 (21-56) 2 ½ Average (2 months weeks months) 5 7 completed and liberty HoNOS score average The scores and daily differences of and Heathrow The majority remarkably are a for completed needs a health to reflect to 19.85, was Wood,

Wood.

reflect The total was the HoNOS one set Gatwick likely 2). (see Figure the IRCs Yarl’s

both certainty and staff. at and Morton Hall HoNOS, subject Yarl’s may is

of of at 2 shows Figure site. on each by completed returned This centres most The HoNOS The IRCs was was Verne conditions living with of the sample high. and lack distress the IRCs but scoring, 35 participants. of of The of submit to asked site. each Detained from a police cell a police from Detained another IRC from Transferred 35 Rule under Assessed Score HoNOS Total Average Number transferred from prison from Number transferred community from Detained the airport from Detained hospital from Transferred Age stay of Length Number Gender 5. The review findings review findings 5. The detainees from data distress, of levels that indicated our data of problems activities characteristics sample 2: HoNOS Figure at score The average markedly HoNOS levels by presented our qualitative with correspond do not and low, both of details at total across varied not in time for data this complete to able not was the review. submit to allowed were one or from on caseloads be based could that Mental wellbeing Mental (HoNOS) Scale the Nation Outcome of Health The HoNOS IRCs. and was review this the time of at assessment

Centre for Mental Health REPORT Immigration Removal Centres in England 14 Centre for Mental Health Broadly speaking, our findings were similar “I left [my country] because I was bisexual to the Shaw report in terms of known mental and my relatives wanted to kill me. I lost health and wellbeing needs. Most referrals to my parents when I was young…if they were mental health services were made in relation still here I don’t think I’d be in this state. My to depression, anxiety, sleep problems and partner was murdered and I fled, I met this trauma. Across the IRCs, there is a small group person who said they could help me but they of people experiencing severe mental health actually sold me into the sex industry. I was problems, including various forms of psychotic trafficked to Europe… I was tortured, raped illnesses. Some of those with such diagnoses and had no access to medical [help]… when I REPORT were well maintained through medication reached the UK I fled these people and then I and regular care reviews. Despite people with was on the streets…” Immigration Removal Centres in England severe and enduring mental illness being a “…these are papers saying my family are relatively small part of the detainee population wanted for being Christian and we are (NHSE 2015 reports that less than 6% of breaking the law so we will be beheaded. the population have serious mental illness) On this letter, those are my children’s names they occupy a lot of staff time and resources, and my wife’s… but my asylum case has particularly so when they require transfer under been refused… I’m trying to stay strong but I the Mental Health Act. During the course of the can’t…” review we met individuals who did not appear to be well enough to be living in detention (e.g. Interviewees discussed experiencing appearing floridly psychotic and paranoid). heightened symptoms of trauma since being Nurses discussed assessing individuals as in detention, such as flashbacks, intrusive “unfit for detention” but that these assessments thoughts (e.g. family being killed at home), were on occasion being overruled by suicidal thoughts, nightmares and problems Immigration Enforcement. sleeping.

Trauma experiences Talking about trauma was difficult and the fact that this might be required for purposes The majority of detainees interviewed discussed of applying to remain in the UK or for appeals experiencing some form of trauma in their life against decisions to remove did not make this before being detained. For example, some any easier. One young man stated: had experienced fleeing a country where their religion, ethnic group or sexuality was “…you can see that things have happened being persecuted; witnessing their family and to me [he pointed to visible scarring on his friends being killed; being a victim of domestic person]…and I can tell you I was hit with violence, sex trafficking or female genital bars and knives…I can say that my family mutilation (FGM); and fleeing a death sentence members were killed and that my sister was because of their sexuality. They talked about the raped, but if I was to say more…give more cumulative effects of a traumatic event on their detail… then I have to think about it and [it] mental wellbeing, for example: comes back to me and I can’t get it out of my head…I would not be able to function this “…I was a child when I moved to the UK and afternoon…” now I’m nearly 40. Whilst I was here my very close family member died. I became Another reported: depressed and started drinking. Then I “…I was given indefinite leave to remain lost my job, my home and was homeless. I years ago, before I went to prison… now they started getting into fights, at one point I was are asking me to tell them all this again…I sectioned because I thought about killing had started to put it behind me…they know myself. Then I got convicted for fighting and all this stuff about me and they are making ended up here…” me say it again…”

15

involves suicide distress vulnerable and

of Teamwork to happening distressed risk departments. the (ACCT), was would wellbeing be killed: would what no reported having Assessment to similar at those other IRC a country to returned being Teamwork multidisciplinary as

However, problems. health on mental is and stated: practitioner health met we managing for system well of because and in Detention Care they believed practitioner) health ACDT experiencing: were mental of risk. extremely feeling described “Here there are some people with existing with existing some people are there “Here here being and problems health mental everyone is there then worse… it makes problem health with no mental people else, emotional so many creates here being but a as of it think to need we problems… emotions the overwhelming where spectrum, problems…” health to mental lead can (Mental the you “…I think can underplay don’t detainees, to for listened of being importance feel and vent to opportunities need they wellbeing…” to their important heard…it’s “I don’t feel as if I have anything to live for… I to live anything if I have as feel “I don’t everything…” lost have detainees Another mental the IRC (ACDT), particularly detainees, is ACDT and self-harm. in Custody Care self- and suicide managing for system prison harm as care health The individuals history they and suicidal freedom”, of “loss uncertainty, of them in terms of and fear isolation, they where as described was in detention Life exacerbates and one which "traumatising” A focus distress. as well as illness mental severe include psychological the broader addressing Assessment

an health They of of state wellbeing Therefore

be seem to mental IRCs and distress. and emotional well. that recognised a clinical reach and depression the needs Across negligible. very not in all someone in which they which problems, be different. was in detention person and staff Staff in some cultures. ache, stomach pain, and assessing screening or may may psychological translate every of and use health may not that and Autism and difficulties, distress They vulnerabilities and respiratory practitioners be life-threatening. and can disabling the psychological to be related their mental to some challenge such needs, known lesser discussed of our understanding to their anxiety to linked were learning injuries, head acquired hidden still distress. experience they the distress but threshold is on individuals met Health Mental for Centre Key the intervention (and therefore individual is required) faces and experiences as such in English, language may anxiety, or way used the language manifests wellbeing on mental An emphasis Stigma discussed also and staff Both detainees mental stigma, particularly services, health mental used commonly how discussed might did not there However, detainees. mental review routinely to in place process any cases. such for wellbeing physical symptoms, such as chronic headaches headaches chronic as such symptoms, physical back and migraines, seizures felt General it was possible that many physical complaints disabilities disorders. Spectrum that acknowledged such for who had detainees of a number met we centres, Hidden needs relating to mental wellbeing to mental relating Hidden needs Staff as

Centre for Mental Health REPORT Immigration Removal Centres in England 16 Centre for Mental Health 6. Impact of detention on mental wellbeing

A key point relating to wellbeing for this The confusion around the legal procedures population is the impact that detention has on “caused a huge amount of distress to their vulnerability. Participants described the detainees”. Solicitors commented on how centre as “hell”, “mental torture” and “like a frequently the law changed, making the prison…a fortress”, and staff observed how process increasingly confusing for detainees. people’s wellbeing deteriorated in detention. Detainees discussed how much stress the legal REPORT procedures caused and often felt there was no Detainees reported that the loss of liberty

one they could ask for help. They discussed the Immigration Removal Centres in England and being part of a prison-like regime posed long waits between communication from the challenges to mental wellbeing. For example, Home Office and how often the Immigration being locked up from 9pm for the night, having Enforcement officers in the centre were not no control over their room-mate, and restricting able to help. Mental health staff discussed their ability to be meaningfully occupied. how they felt “clueless” and powerless to offer Detainees discussed how specific aspects of emotional support around detainees’ cases. In the environment, like the locks and no fresh air, some centres, detainees described how they made it feel “suffocating” and like “captivity”. were discouraged from mentioning their legal It should be noted that regimes and ‘lock case in their therapy sessions, even though down’ varied across the IRCs and sometimes they felt the need to vent. As can be seen in within an IRC. Campsfield House was generally some cases it clearly impacts upontheir mental acknowledged by staff and detainees to have wellbeing. Offering both practical support (i.e. the least restrictive regime for men (Yarl’s Wood helping them to make a call to their solicitor) appears to operate a relatively unrestricted and emotional support (i.e. acknowledging their regime for women). distress) in these sessions may help to alleviate The level of uncertainty about their future, some of the distress. compounded by poor communication, The lack of social integration amongst detainees contributed to poor mental wellbeing. in IRCs due to the transient and distressed ‘Uncertainty’ featured prominently in the nature of the population led to detainees feeling accounts of detainee distress, for example: isolated: “…I just want a f*****g decision…there is a “I feel really scared, alone and suffocated… In war back there [in his country of origin] so the community I had friends but here there is they won’t be removing me, but they won’t no one…” make a decision either way… [it] just brings me down…” Some detainees discussed how they felt more integrated with other inmates in prison because “…I don’t sleep with worry…I can’t focus on there were initiatives, like prison councils, doing things…I don’t know what is going to which provided opportunity for socialising and happen…” building a community. However, at the IRC these “You just don’t know what’s going to happen detainees described feeling much more alone: to you… only your freedom will change this… “At prison I was integrated into the system that is the only way to relieve stress…” and was focused. I had a job in the laundry “I am very scared by the people who’ve been place and a role at the prison council so that here for a long time [starts crying]…one uplifted my spirit. Here I spend more time on month is okay, but a long time is very scary… my own with nothing to do…the problem is I can’t sleep, my mind is going crazy at night everyone is in the same boat and everyone is time…” in their own world, thinking about their own stress, so there’s not much integration…there isn’t anyone to talk to in the centre. Like my roommate is in a different world…” 17

a being and then is The following report they where an office forewarning. on the told mentioned being been had to spoke we the people of account: “…you’ve done something wrong, so they so they “…you’ve something done wrong, time. you do your you put away…rightly…and on changing I worked the courses, I did all and did change life around…I my turning and early earn can I had changed…you saw they it's and happening what’s know release…you fair…” no answers…I are there here…well, “…but get don’t caseworker…I to my speak stuck…” just am anywhere…I an IRC. to be moved to going routinely to required were without “seized” Several and they their detention prior to in prison the experience. contrasted typical He continued: Some detainees were they ended that sentence their prison day at Some reported arriving

for re-traumatising detention. prior to be the case to appeared and men “raids” morning This as described who had to spoke we those for “…I have never committed a crime and they they crime and a committed never “…I have me in a police left and that me like took cell…” I’m having to share and now I’m reliving my my I’m reliving now and share to I’m having for support any if I get as feel I don’t But past. this…” it feels like the captivity I experienced when I I experienced the captivity like feels it slave…” was a sex I’m having process the immigration “Through trying I’m that life of my sections to relive inside deep buried I’ve things to forget... “…being here is reliving my trauma because because trauma my reliving is here “…being traumatising. residence. as particularly been in the community Some reported early of their place entering in uniform and women In addition, the point and manner in which in which and manner the point In addition, described was detained were some people was Detention some people:

Centre for Mental Health REPORT Immigration Removal Centres in England 18 Centre for Mental Health 7. Services in place across the IRCs

This section provides an overview of the Figure 3 provides an overview of mental health services currently in place across each IRC and assessments and interventions in the IRCs over then discusses examples of good practice. seven days.

Figure 3: Numbers of assessments and interventions in IRCs over 7 days REPORT Morton Hall Campsfield Gatwick Heathrow Yarl's

House Wood Immigration Removal Centres in England Number of mental health 6 3 52 10 9 assessments Number of medication reviews 2 10 3 14 Number of care reviews 3 Missing data 52 10 32 Number of one-to-one pscyhological 2 2 0 0 0 interventions (psychological (counselling) intervention) Number of group psychological 0 0 0 0 24 interventions Number of individuals attended Missing data Missing data N/A 4 another type of intervention Number of detainees who have Missing data Missing data 4 25 2 received onward referral for a mental health or related vulnerability Number of unattended appointments 5 N/A 50 0 5 ('Did Not Attend' - DNAs) Number of detainees treated with NK 3 11 65 11 medication for depression Number of detainees treated with NK 6 2 15 6 medication for anxiety or stress Number of detainees treated with NK 1 1 16 3 anti-psychotic medication Number of detainees treated with NK 7 2 27 4 sleep medication Number of detainees assessed under Missing data 11 7 43 10 Rule 35 Number of detainees on an active Missing data 6 7 48 0 ACDT

Figure 3 shows some apparent and marked ACDT at Campsfield House, and that there are differences in statistics reported by each IRC no reported ACDT cases at Yarl’s Wood on the for the census date upon which the survey was same day. Additionally, Heathrow has notably based (on 31 March, 2016 or in the period high numbers of detainees being treated with leading up to it). Most notable are the high medication for depression or sleep problems. volume of assessments at Gatwick, the higher In addition, the rate of DNAs at Heathrow is rate of unattended appointments also on the surprisingly low. One possible explanation is Gatwick estate, the large volume of detainees on the outreach approach of the mental health 19

and estate. and group.

Trust. be the four for

Trust Trust. between RMNs, one includes health wellbeing Gatwick. approach per week slots This by provided across

form. health introduced have Foundation one-to- ongoing staff

They Foundation Foundation emotional a weekly who run all mental one day for new assessments). and two for be to estate up the whole mental running reviews. in ACDT involved will provider) sector a one-contact agency two lead), intervention. appointments Approaches the individual. provides is a including assessment, for the example, For place. a weekly the through provided also are techniques. and relaxation Morton reviews. and follow-up therapists training is team

takes assessment voluntary and has at their service planning beds care a stepped been introducing vehicles

NHS Partnership NHS Partnership psychologist is There reviews (two is service care The health – a has and addressing wellbeing in promoting of the time-frame symptom also but therapy, narrative include management The psychologist awareness chaplaincy Morton Hall a clinical of comprises the team Currently the also (who is health mental for matron disability learning clinical per one session for psychiatrist one consultant week. NHS care Health Nottingham initial conduct team health The mental assessments Hall skills model, which support. provide to able various interview ideation a suicidal interview, suicide and a risk The psychologist one psychological to tailored is which therapy, trauma-focused Trust and are service misuse a substance providing currently Sussex two and psychiatrist, the consultant provides occupational a day half there is psychiatrist The consultant per week clients Hospital Sussex assessments initial of consists The service the by delivered reviews care and follow-up RMNs. uses which group, distress detainees’ to on listening focusing strategies. and coping their resilience building seen as are and chaplaincy team The welfare key work and collaborative vulnerability, the teams Prisoners Addicted for (Rehabilitation RAPT

be

The Tinsley and in

of trauma (RGNs). level low sensitive the nurses and the IRCs The position medication Therapies

role. is may There re-ported Wood Nurses

consists some numbers and anxiety. sleep been filled. and containing see example, (for Nurses Health RMNs three on trauma. focusing NHS London IRC House Yarl’s Registered a week, the work high ensure to working psychoeducation, West (RMNs), a substance recently as a senior RMN. distress and complex PTSD Brook and mental the health of regime relaxed sessions 5). in chapter of intervention specialist a day Psychological to is of well primary the embedded provide as expected. than higher or lower and GP’s. One of officer is those Trust Heathrow’s service. a single levels and North scores this to recruited being half for culturally in providing role Mental Registered currently are There address To as the most and population, address to introduced being consists has House Campsfield engagement. of as such issues, health Nurses Health the wings time on visits Harmondsworth are and Colnbrook. of a psychological function. one of post; a fourthfor RMN has G4S IRC. House and these teams, care health and mental health consist General (RMNs) and Registered health mental a dedicated provide RMNs important support. Gatwick Gatwick six up to are there Access Improving is (IAPT) mental an play team the chaplaincy Additionally, generally provided The service care and follow-up assessment an initial Predominantly reviews. management strategies coping developing distress. Mental an and part-time consultant, nurse misuse engagement is another is health care provider at both Heathrow sites sites both Heathrow at provider care health and runs IRCs a psychiatrist of comprises team health mental who markedly are Heathrow The Central Foundation arguably the and has analysis the needs of part as visited smallest the highest the HoNOS in the reporting as some error nurses at Heathrow who deliberately spent a spent deliberately who Heathrow at nurses lot patient

Centre for Mental Health REPORT Immigration Removal Centres in England 20 Centre for Mental Health Campsfield House and sees approximately eight service users per day, in both one-to-one and group sessions. Campsfield House’s health care services are This uses a range of approaches such as now provided for by Care UK and this change talking therapies and relaxation techniques occurred during the review on 1 April 2016. (for example, massages, relaxation tapes and At least four of Campsfield House's six reflexology). Yarl’s Wood also has a weekly permanent nursing staff has a mental health session of psychiatry provided by SEPT (NHS qualification (RMN), either as a sole or dual Trust). NHSE had made the offer of some REPORT qualification. One of the RMNs is also the senior small grant funding to three groups who offer or lead nurse. There are six additional regular listening services at Yarl’s Wood. Immigration Removal Centres in England bank staff and some of these may also be RMNs. The following two IRCs were not visited as part The nursing function at Campsfield House is a of Centre for Mental Health's mental health generic nursing function, with at least one RMN needs analysis. In each case the most recent on shift having responsibility for conducting health needs assessment (HNA) findings are mental health assessments and then making summarised here. decisions on referral (typically to the GP, secondary care or the sessional counsellor). At The Verne - Health care provision the time of the visits, Campsfield House had some sessions from an Oxford-based secondary and summary of evidence on mental mental health care service. wellbeing It was predicted that the nature of the mental The decision not to visit the Verne was made as health care offer would change and that it was subject to a Health Needs Assessment psychological care would become more (HNA) at the time of the mental health needs available. analysis and it was agreed to use the pertinent findings from the former (Lewis & Meek, 2016) At the time of visits a counsellor offered two to inform the latter. sessions per month for one-to-one counselling. It was not possible to speak to the counsellor The HNA looked at all aspects of health care and learn more about this service. at the IRC. Like all IRCs it had a significant turnover, averaging 474 detainees at any point Yarl’s Wood but a similar number pass through the IRC each month. Mental health provision was offered There is currently one senior RMN, one full-time through a stepped care model. The mental RMN and an agency RMN (a third permanent health services offered an integrated approach full time equivalent RMN is being recruited). (i.e. primary and secondary mental health The psychiatrist attends once a week. There care were merged within a single team). It was is a nursing assistant who, at the time of reported that 14.3% of the population had the survey, provided a wellbeing service. A been referred to the mental health service; this charity, Kaleidoscope Plus Group, has been amounted to an average referral rate of 63 per commissioned on a two-year pilot basis to month. provide psychological interventions. At the time of the need analysis and drafting of this The HNA reports the average prevalence rates report, they were recruiting a full time IAPT as: psychological wellbeing practitioner. Depression 6.9% The bulk of the RMNs’ work is initial Psychoses 4.0% assessments and follow-up reviews. The wellbeing group is provided Monday to Friday Other problem 7.2%

21

time The that

recent this no in a is transfer Chief a busy for occurred have suggests part ‘re-rolled’ had in published 2015. At may This in 2014. prison was There Verne. report, conducted C facility holding term was (HMIP to referred high and the been had The

This Her Majesty’s was took Verne a short by illness The that in the population changed days. one or two often staying , 2015). Prisons it since tripled had place. taken had in February Health from transfers. health a category from 2015 and changes et al al et The Inspectorate’s 2016). 28, Durcan, (see page prison of and the rate receives, Verne expect one would higher than an IRC mental severe mental Pennine House - Health care provision provision care - Health House Pennine on mental evidence of and summary wellbeing is House Pennine detainees with visited be not would it that decided was It be used HNA would recent the most and that (Cairns February the most In addition, in the meantime. report inspection of Inspector 2016). at service counselling Clinicians national funded Health of Department mental between on the interface consultation Centre by conducted justice, and criminal health Mental for the Mental under transfers reported that was it Act Health as the levels view in their reported that Clinicians of Act Health the Mental under transfer need for was local prior to months in the six HNA reported that the Mental under one transfer completion, its Act Health has something The reduced. much of

two

and Trust There these health mental by provided a prison need, but that team. worker. health of offered Verne services health the Learning to psychologists, mental care

Foundation The and coordination suggest An hours. in office emotional help for one psychologist, mental care one consultant workers, assistant care health assistant mental care seek and access intervention health therapy was team health WTE two the weekend over team health may the report provision. covered care health of such four to equating self-harm mental be to assessed month period) were been implemented had ACDT torture. support (LD) intensive of per month. be underestimates to secondary psychiatry of workers, community five lead, health support health service. health University Care Health mental However, a week. WTE detainees no mental one psychological Disability was and primary Secondary one-to- monitoring, medication included primary three workers, health health mental one clinical psychiatrist, specialising one doctor psychologist, chartered in adult primary(WTE) in-house one 0.5 worker, one of comprised team The integrated mental physical health care 24 hours a day and seven and seven a day 24 hours care health physical days Monday-Friday operated mental integrated Dorset time equivalent one whole of and comprised 128 times in the same period with 23 recorded 23 recorded period with in the same 128 times incidents incidents health the mental of details The report outlined IRCs, other Like provision. problems from their peers or staff outside the outside or staff their peers from problems mental new detainees 3% of reported that also was It a six (over victims The authors likely are that

Centre for Mental Health REPORT Immigration Removal Centres in England 22 Centre for Mental Health in January 2016, reported that 16 people were suicide, though of the 4.3% of detainees over detained there, 12 men and four women. The a four-month period who reported a history of average length of stay was 37 hours and 51 previous self-harm less than 1% of detainees minutes; with the longest detention at the time over this period were felt to pose a risk on being seven days (records for a longer period admission to Pennine House. Cairns thought indicate the longest period of stay had been this may be an underestimate of the likely 12 days). Most detainees were independent detainees posing a risk of suicide attempts and travelers whose ages ranged 18-70 (average 32 self-harm. This was based on comparison with years). A concern for the Inspectorate was that data on women prisoners and prisoners more REPORT men and women shared facilities. This report, generally, and known risk in these populations based on an unannounced visit, was largely (12% of detainees at Pennine House were Immigration Removal Centres in England positive and reported that recommendations women and approximately 25% were former from the previous visit (in 2013) had been prisoners). However, Centre for Mental Health achieved with exception of men and women interviews with clinicians across the IRCs having separate facilities, greater access visited suggested that IRC detainees have a to the internet particularly for legitimate very different profile to prisoners and also that communication and accessing information, and this applies to former prisoners (i.e. they as a the relocation of the visiting facilities (currently group do not have the same profile as a prison held in the reception area and sometimes population). during receptions). Obviously in the context of Over a four-month period only 6.5% of the this mental health needs analysis such issues population had previous known history of poor have a potential influence on wellbeing. mental health and/or mental health service use. Cairns and colleagues (2015) reported that Once again less than 1% was deemed to have the health care team comprised of nurses a current mental health need. In the previous with access to an on-call doctor, although this 12 months, one detainee had been transferred was reported as used rarely at the time. The under the Mental Health Act. Cairns et al . team had two full time nurses and four nurses (2015) reported that little more than screening working 24 hours each per week (plus regular and assessment can be offered by health care bank staff) and provided 24/7 care - one nurse at Pennine House due to the rapid turnover of being present at night. At the time of the HNA, population. Cairns and colleagues (2015) were three of the staff had both mental health and concerned about how isolated the health care general nursing qualifications, though it was team was (Centre for Mental Health also had this unclear what this meant in terms of mental concern over the health care teams it visited). health trained nurse coverage. Cairns and colleagues (2015) recommended closer working links with peers at HMP Style, The primary concern with regards to mental which is relatively close. wellbeing was reported as risk of self-harm and

23

at

(e.g.

the and seen has of mental them to and term deliver to Trauma discussed of a which to offering and offer was Stepped tiers in developing informed had visited

on lower the detainees Staff short This (i.e. the estate Morton as Hall, of on the assumption interventions offers. therapy example, (2011). For be provided would The extent centres different the highlighted also progress potentially provide to be able to support). A wellbeing across a week in once that NICE psychiatrists having They an emphasis mental extensive delivering officers general in the community…e.g. tiers. detainees. with at targeted strategies coping develop to All centres. a stepped deliver to able in being was seen as are works approach mental for in psychological psychological adapting discussed outlined by the most made needs the wellbeing psychologists interventions short-term higher-tiered as the clinical example, for work, tiered only discussed by required as centres a psychological for plan “equivalents important interventions to suit a one-contact approach approach a one-contact suit to interventions only for IRC be in an will (some detainees one just have period and may very brief a opportunity one-contact have and intervention may assessment that the due to session, in the same place take to by Morton Hall schools”. families, nurses, arguably its model care a stepped in developing At delivery. service wellbeing well EMDR and Narrative (e.g. trauma for was there Therapy) level psychologist staff to training health support to staff) Home Office officers, needs health and identify mental understand psychologically more have and to conversations as to be equipped would staff all as care of model address the lower-level All by followed health, and promote wellbeing interventions, and guided self-help self-help formal more to climbing before treatment term then longer models care efficiencies 2005). & Gilbody, Bower been operationalised had model care stepped across varied interventions short-term example, model, for care stepped interventions sessions. wellbeing and group care a stepped of implementation full to barriers model staff clinical work. higher tiered skill work the lower-tiered

of

and Wood staff

was.

the of centres maintain section Yarl’s a Such and care The lower people the IRCs. outlined the mental This (RMNs) across that and talking is them encouraged be. all across the Heathrow recruited being coping and build in post. at him. with trauma treat to need across visited. wings on to going

needs promising or good it accessible how of the importance seek of spoke House Campsfield as patients. their engage to Nurses Health One interviewee in detention. having this, in achieving fantastic providing in general provision care health the IRCs by recognised members The services psychological for in interviews. raised practitioners of the greatest support for been commissioned interventions include staff how discussed about talked whilst staff about examples were There All their stress. manage helped them to higher levels up' into 'stepped generally might felt across specification England detainees was estate at to spoken those only was 8. Good, promising and well received practice and well promising 8. Good, at the lowest tier possible and the patient and the patient tier possible the lowest at is professional tiers was practitioner and an IAPT the needs the time of at the new provider by model care A stepped analysis. in the delivery model health the mental as NHS models care Stepped interventions. made have to appeared and Morton Hall IRCs progress greater psychological has service Psychological interventions Psychological It Health Mental for Centre providers health that to spoke IRC they of positively by impressed and were them in in with and checked who acknowledged passing. individual work outreach doing Detainees which and education, in activities participate to way they listened to detainees, and that they they and that detainees, to listened they way their distress helped contain strategies very the nurses he found how discussed his supportive in exploring Detainees staff care health support. Mental Registered in the helpful as described were the centres all in all practice those and particularly these some of describes that told observed and were we the centres Across dedicated of members about detainees by examples were There

Centre for Mental Health REPORT Immigration Removal Centres in England 24 Centre for Mental Health rapid turnover of detainees and therefore the Psychological Formulations undefined and potentially short duration of detention. Of particular significance is the These can be described as having the work being done at Morton Hall in tailoring following characteristics: the intervention to the time available. Once a • A summary of the service user’s core detainee has been referred to mental health, problems; the team contacts the Home Office to find out where the detainee is up to in their detention • A suggestion of how the service user’s process. This gives them a very rough estimate difficulties may relate to one another, by REPORT of how long they might have with them and drawing on psychological theories and helps shape the ‘offer’; for example, if someone principles; Immigration Removal Centres in England is at the beginning of the process and is going • The aim to explain, on the basis of to put in an appeal, the team know they have a psychological theory, the development while to work with that person. If the detainee and maintenance of the service user’s has exhausted all appeals and a flight has been difficulties, at this time and in these booked, they know they may only have a couple situations; of sessions. In this instance, the intention of the sessions would be to help them develop coping • Indication of a plan of intervention which mechanisms that they take away with them. Of is based on the psychological processes course the time is subject to change, but it does and principles already identified; mean that the team are making the most of the • Being open to revision and re- time they have to provide an effective and safe formulation. intervention. (Johnstone & Allen 2006, cited in British Psychologically informed approaches also tend Psychological Society (BPS) 2011, p. 6) to use psychological formulations to understand the wellbeing or otherwise of an individual. Formulations are an attempt to understand an These take the forms of narrative descriptions of individual in their context, and to do so using the person and their problems and the context ‘plausible account’ (Butler, 1998 cited in BPS, in which both sit. Such formulations inform 2011) in the form of a shared narrative rather interventions and the narrative changes as the than a categorical diagnosis. The formulation person does. It struck Centre for Mental Health provides a hypothesis to be tested and its as a particularly useful way for mental health narrative changes as the individual does. services to understand the need of a detainee. (Taken from Durcan, 2016)

Wellbeing sessions (Yarl’s Wood) Yarl’s Wood ran daily one-to-one and group Trauma focus wellbeing sessions, which included talking Morton Hall, as part of its psychological therapies, relaxation, massages, meditation intervention offer, was also developing and reflexology. Whilst the evidence base for approaches to working with people who have what the wellbeing service offers is limited, it experienced trauma. They discussed using a was well received and highly regarded by the phased approach (see Robertson et al 2013) detainees we spoke to, who stated it provided using stabilisation and symptom management a relaxing space and one where they could vent for individuals there for short or uncertain and alleviate stress and tension. This was seen periods of time. For detainees who were there by detainees we interviewed as very important for longer they discussed examples of using in relieving immediate stress and developing Narrative Therapy. coping skills: “I find the massages and having someone to talk to calming”. It was accessed by many detainees with varying mental wellbeing problems, including patients who were experiencing psychosis. 25

and

in the service for asked across those for Health health. in place. was team participate the findings). care Health and was groups working close community. were these olds year IRC hospital dedicated runs Verne in providing role very in transferring but

For the population. that Verne’s the sure make to The of of

The chaplaincy The Gatwick the group to be similar to forums that at Lewis House. Campsfield they and ensuring was there House, and Campsfield a key playing the needs taken had Gatwick) example, (for issues). consultation holding discussed appears times transfer in reducing over-55 Gatwick, trained having team, the care into detainees with support. Detainees sensitive key This provides partnership attended. (2016) report detainees for the centres the religious from received the embedded further and have a stage both Gatwick House. Campsfield department has previously attempted to run run to attempted previously department has specific care health poorly They were often described as more accessible accessible more as often described were They someone in mental see to going than Some centres this chaplaincy roles counselling in ACDTs. detainees with groups Consultation At stakeholders meetings meets service at example, be put to morning and bingo a coffee attend to able were Health Mental for Centre at group one such Meek representatives care health that forums user attend. at Partnership and collaborative and collaborative Partnership working reported delays were There Health the Mental under hospital to detainees described is (this the IRCs of several across Act section of the 'Challenges' in later Sussex beds as cited the Mental under admission requiring Act. In all and welfare the chaplaincy with relationships provider the security by employed (teams teams advocacy and in some cases advice provide to of on a range as recognised culturally support the crucial to referred consistently sites they partand in being centre

of

where

for

of of wellbeing on a based (CBT), “the tap or flight’ and Enright, is and turnover validating actively in IRCs in place care The health approaches and detainees the possibility examples across cited In reality, stay. and detention in living psychoeducation emotional therapy of put to was staff it take I can inside, in peer mentoring been released who have as such aids, a solution- and using when House Campsfield the peer support valued It detainees. routinely wellbeing men Jamaican older experiencing who were (Powell stress” a weekly care. health did suggest Several of also visual their one another through

of value for wellbeing; managing to the impact were people where the group, therapy fast the model, given length of around of of on a range draw was the approach to the ‘fight and activating key uses model uses The approach and mental about as runs House afternoon. reviews offered House Campsfield skills. and coping resilience demonstrated At detentions. longer three them for been with had a detainee an interview for on invited were they months at their wellbeing an interview developed tool had manager this. reviews Only physical detainees those for staff uncertainty, individuals employing a peer provide to experience experts by as role. mentoring wellbeing detention Longer-length described how they met to play dominoes dominoes play to met they how described every the discussed difficult Although prison. the of in the midst also are the “peers” because out”. Detainees component support to able support Peer difficulties. centres of a group example, occupational approach. focused found they helpful how discussed Detainees and to listened felt they because space this “what’s offload: to able up their self- build trying to their distress, out and pointing compassion they The groups behavioural cognitive from think to on anxiety It system. and glass 1990). Key participants the to listening one contact uncertainty and once than more went the detainees of many several for going been some who had were there months. Emotional wellbeing group (Gatwick) group wellbeing Emotional Brook eight up to for group

Centre for Mental Health REPORT Immigration Removal Centres in England 26 Centre for Mental Health 9. Challenges

Before detention groups, for example women and those under 18 years). Likewise, screening could be undertaken There was an expressed desire both by NHS for any detainee in court served by a Liaison England and the Home Office that vulnerable and Diversion service. For those coming from people should not be detained as stated in prisons it would be possible for mental health the Home Office Adult at Risk draft policy professionals within the prison to conduct a REPORT (UK Visas and Immigration, 2016). There is screening or fuller assessment for those not currently a missing component in the process known to them and to provide an existing Immigration Removal Centres in England of making the decision to detain someone. assessment where they are known to the mental At the moment there is no screening in place health teams (the latter does usually happen, if to detect vulnerability before the decision is not always in a timely manner). made to detain. It was reported to Centre for Mental Health that in most cases vulnerability is Short-term holding facilities such as Pennine discovered after detention. House do hold people for long enough periods for screening to take place and might also Any pre-screening process would need to benefit from the extension of the NHS England’s be completed independently from the Home Liaison and Diversion system. For those Office by a competent health practitioner who detained from other sources (e.g. lorry drops) is qualified to assess a person's vulnerability providing a pre-screen is more challenging and and potential impact of being detained and is not currently part of NHS England’s remit. this process is without the purview of NHS England. NHS England currently commissions Communication an equivalent type of service in courts, youth offending services and police custody suites On arrival, there is no guarantee of information for over 70% of the English population. These flow regarding an individual’s vulnerability liaison and diversion services screen and assess from the detention source (such as from the for a wide range of vulnerabilities and guide community or prison) to the IRC. Stakeholders decision makers as to where to place suspects working in IRCs said that there was greater and offenders. Although not possible to screen chance of getting information from the Criminal all detainees before they enter detention, it Justice System and psychiatric hospitals, but should be explored how best to detect such not necessarily timely access as the information vulnerabilities, which might impact decision may arrive after the detainee had been making on immigration detention. screened, rather than with the detainee to form part of the screening. It was exceptional for Employing screening tools would create huge someone to arrive with their notes available. challenges in many cases of detention; for By the time practitioners in the IRC had sought example, where migrants have entered the UK consent for the notes, contacted the previous concealed in heavy goods vehicles (commonly provider and received the information, the referred to as “lorry drops”). However, in cases individual had often moved on. where prison mental health teams or Liaison and Diversion services in courts and custody are Screening involved, staff should be mindful of the needs of vulnerable individuals and raise concerns Screening took place throughout the day and regarding the impact of detention. Those that night, and seemingly in less time-pressured come through police custody could be screened circumstances than other custodial settings. where an existing Liaison and Diversion service However, screening for learning disability, is in place. The operating model for such autistic spectrum disorder and acquired services could be adjusted to include screening brain injury were all perceived as “weak” all such detainees (currently many Liaison and “very limited”. Some IRCs had screening and Diversion services screen 100% of some tools for learning disability. None reported

27

When

was primary in ideation. some in sitting mentioned of The larger detainees and triage advice (e.g. the Heathrow described referral. a nurse for of and backlogs and physical access. and manage on how training little and often basic. varied

of consisted ‘torture’ supported. At All or self-harm. suicide effectively used being managing for the training a GP. for and longer 4-5 staff having alternatives to Campsfield Heathrow. of is significant pose can detention of suicidal to relating what 35. Changes Rule for ‘application’ have to tended care health seeking for support to instance for delays, longer had risk support. However, in providing Campsfield like IRCs, Smaller days two within and demand, increased having very and, as pharmacist) at best were their mental to days two up to take waits longer had the regarding raised also were play element triage the nurse to centres access have questions but well, compare to appear things. that discussed might they role staff was someone on ACDT was there example, For ask to Questions appropriateness Rule 35 Assessments Some IRCs in assessments the definition of seen as were centres larger Harmondsworth at demand reported also the increased House complete to able were review the time of at but assessments reviews ACDT process The ACDT across individuals services appropriate be involving to appeared that ensure to in the review the centre within individuals staff Gatwick, example for centres, the recognising the chaplaincy, involving Access and IRCs, all across reasonable was care GP appointment a accessing although often could centres smaller variable, more or next-day same- provide establishments type processes in those to dissimilar too not appointments, to detainees by felt were and these prisons, delay day same guarantee could House, whereas often GP appointments, IRCs appointment triage IRCs in the community, access to compared might do not a local from their earlier, challenges wellbeing. Access to primary care to primary Access

(in

the how

they was after was Whilst detention to It heard. we on screening stage second by developed performed under that commented custody). that managing 48 -72 hours many of observed meant be if traffic. daytime avoid to the night just be questioned to occurs and in, the training centres, night Some staff all in prisons practice common tools screening validated at process. follow-up an initial receive is usually has also process screening reception way humane of, automatic an have in aged One detainee, deprived. sleep of one example travel and court in police this an older whether moving be asked to very in the day. of in the middle was vans do not detainees who had nothing. I asked for a shower and and shower a for I asked who had nothing. I was morning. until to wait I had told was later”. IRC] 3 days to [another then moved [for] a blanket and they wouldn’t give me one me one give wouldn’t they and [for] a blanket prison “that’s said, they and why, I asked and I was to cry. started when I was you”…that for about at cell my into got to [IRC] and taken given I wasn’t some PJs I had 4am. Because people for only was it said they as anything “I was at a friend’s house at 8:30 in the 8:30 in at house a friend’s at “I was I was raided… got the house when morning was which 12 hours for cell to a police taken a was there as day all cry I didn’t cold. very I asked when was It praying. I was and bible the most no automatic adult is It situation. will a screening reliable is there as and especially circumstances, such This needs the late arrive individuals that means this However, staff in the night, which were us: their 60s, told 24 hour reception 24 hour a day open 24 hours is in IRCs The reception any at and leave arrive will people and therefore point All a GP appointment, offered and are arrival, but as screening prisons arrival). services the general across standard availability variable. the tool example, for having, injury (used brain acquired for Trust Disabilities and Diversion Liaison and by prisons in some

Centre for Mental Health REPORT Immigration Removal Centres in England 28 Centre for Mental Health on the meeting with one detainee. From our Clinicians discussed how they often had no time observations and interviews, we questioned to help someone prepare for being deported, how safe the detainee might feel to talk openly sometimes receiving notification after a removal about their vulnerability in front of several had happened. If they were given a time-frame, members of staff. they might be able to provide some “stabilising” support (e.g. developing coping skills, linking Hospital Transfers up with possible support systems) towards that. For example, the communication between the

The longest time cited for a transfer to hospital REPORT mental health team and Home Office at Morton was four weeks (at Yarl’s Wood), and it often Hall means that the intervention can help equip took between two-three weeks. This was detainees with skills they can use following Immigration Removal Centres in England seen to be caused by the shortage of beds. removal. One detainee told a clinician that he This measure counts from the point at which would take the coping skills he had developed someone is assessed to the point the detainee through the psychological sessions away with is accepted to a unit. In reality there may be 1-2 him. weeks prior to this when the mental health team at the IRC assessed the need for transfer and Health care staff often had concerns over the made the referral. Therefore the actual delay likelihood of a detainee’s deterioration in experienced by the detainee might, on occasion, wellbeing after removal where it was uncertain be five weeks. For a small mental health team, or unlikely that continuity of care could be looking after someone who is too unwell to achieved in the country they were being be in detention takes up huge resources. At removed to. Staff discussed the difficulties of some IRCs, staff discussed having to use the trying to support someone when there was no care and separation unit or segregation unit for assurance of the care they would receive on people whilst waiting for a transfer as the best return or even if they would be okay. Detainees environment for unwell detainees at the centre. talked about fear of death and torture on However, staff commented on how this made returning and clinicians felt they could do little them worse, increasing paranoia and isolation. to reassure them. The separation unit is not an acceptable place for someone to stay; however it was seen as the Leaving an IRC and continuity of care lesser of two evils. The overarching concern is When the decision has been made to release that people who have been assessed as needing someone, staff reported that they were usually hospital treatment are not receiving it within released in the space of approximately two appropriate timescales. hours. In seeking to ensure that no one is unlawfully detained, the rapid release does Removal mean that if the individual is a patient with a One of the 'ethical' challenges for mental health centre’s health care, nothing is being done in care staff concerned the removal of a detainee relation to continuity of care. Mental health where it was felt by staff and managers in the staff discussed individuals going off to court IRC that if the detainee had advance knowledge and then being released from court. This is of their removal this would increase risk of most troubling when a detainee has need of suicide and self-harm. We were told how this secondary mental health care support. led to refraining from telling someone they “…so they are stable with us here, we see were being removed until legally required them regularly, they take their medication… to. However, the lack of transparency does then you’re told they are being released…I contribute to a lack of trust towards staff and have had that on a Friday afternoon and a “culture of fear”. Clinicians found this one you try finding someone to refer them to on of a number of “ethically challenging” issues a Friday…I’ve just crossed my fingers and they faced working in IRCs. It also means that hoped they make it through the weekend…” support before the removal is not always geared (Mental health team member) towards building up a detainee’s coping skills.

29

since for

tried in an and some are GPs, (e.g. lying were staff head your a re- or ask on resources, in a more staff they in “covered exacerbating and therefore if and distress stigmatising interactions and private to ask to wanting this how described detected. being been “treated had not not as detention be less of vulnerabilities whilst and officers)

going around stigma also of “keep to better but problem health as described the flexibility provide detainees needs some officers access With and experiences manhandling” as and treated was airport the from of it was may is There they where staff care health on the wings, difficult discussed unmet need. express to Several This some cultures. emotional Addressing manner. of nurses health may wellbeing individual how Some discussed likely “Here you go round in circles…no one helps. helps. one in circles…no you go round “Here in round goes it but fault anyone’s not It’s on health the blame putting been I’ve circles. to by listened getting not they’re but care else…” anyone and security care both health a mental having back coming the risk heightening detainees Additionally, experience. traumatising the impact discussed help and that increasing quiet, therefore keep and down” the risk by mental IRC. impossible it made the system help them but to anything: achieve to Detainees officers with horribly…lots of bruises”. they where fear”, of a “culture to contributed of “scared” were less psychological when experiencing help for distress. experienced, already distress mental of levels care. health particularly services, support health mental to amongst and reliant challenging Although on an emphasis with approach an outreach engagement detainees spaces safe individuals and engage go could informal mental see themselves not who may individuals, for as stress increased experiencing detained. being mistreated or ignored of being Experiences their discussed the detainees of Most not to, listened not were they that perception seriously taken not want to leave their room and come up to up to and come their room leave to want not

to

With when were We care health reported the fast accessible if relapse escort limiting overseas. released being access have not (DNA) attend’ 30-40% being engage. to several are There locality. background health for used be could in the residential legal example, (for releases notice any for medication) those released, being observed that private be adequate to those were concern (that shortages continuity Short the case. ever and the concern illness, place. take to was regime the ‘did not staff willingness rarely visited. detainees for was the detainee

is needs There treatment or equivalent if did not or therapy) care the health elsewhere, stated on the wings given were the above to similar rates reported (higher than as such DNA rates, high for In some cases place. take to staff the latter, to and therapy the centres the IRCs of a likelihood to often related that for the provider also all and patient units) regards may they distressed particularly are individuals other meetings on, moving and people turnover priority taking residential visits), for and facilities capacity limited availability, detainees (seeing ‘outreach’ Across are appointments health mental for rates 50%, but and up to high quite typically 2015). see NHSE, previously, reasons reviews health of mental Non-attendance appointments the offices assessment the necessary and SystmOne information. translation the necessary with spaces and safe for notes, clinic available and readily equipment Centre for Mental Health observed across the observed across Health Mental for Centre rooms private number of an inadequate centres and clinics for facilities the necessary with therapy and facilities translation have did not rooms and mental health care teams were small and small were teams care health and mental the explore to capacity of in the way little had of likelihood equipment and to rooms Access greatest the who caused mental enduring with was treatment a similar current (e.g. As reason. problematic provider health mental the IRC where an area to was this informed the individuals Regarding Accounts at less somewhat but problem, a always were

Centre for Mental Health REPORT Immigration Removal Centres in England 30 Centre for Mental Health Although officer conduct falls outside of NHS LGBT issues England’s remit, it is important to recognise that wellbeing is the responsibility of the whole Several of the men we spoke to reported establishment. Any aspect of the regime or that they were gay. All reported suffering detention experience (e.g. difficult interactions psychological and physical abuse (two men with staff) which exacerbates mental health reported being kidnapped and beaten by vulnerability, risks increasing the burden on civilians in their community in their country mental health services. of origin, and another reported being

sex trafficked) as a result of this in their REPORT New Psychoactive Substances (NPSs) home country. All reported that UK Visas &

Immigration Service was suspicious of their Immigration Removal Centres in England NPSs (e.g. synthetic forms of cannabis and reported sexual orientation. Likewise all tablets with similar effects to ecstasy and reported fear for their life if 'removed'. One amphetamine) are a considerable problem commented that he did not feel safe revealing across the prison estate, in the community, his sexuality in his IRC as he reported that many and in parts of the IRC estate. All IRC health detainees held homophobic views, and he care teams reported incidence where they had worried for his safety. Such a concern adds to suspected use, giving examples of marked and the burden on a detainee’s wellbeing. rapid deterioration in both physical and mental health. Centre for Mental Health was given one One member of staff also reported that other account where a more vulnerable detainee was LGBT people could feel threatened if their allegedly encouraged to try out a substance orientation was known, and especially amongst before other detainees took it. Similar accounts people from their own ethnic or cultural group. have been given in prison. NPS use has been Although this issue does not directly involve a major challenge to the limited resources in health care staff, it is crucial that aspects of IRCs, both in terms of security escort for those detention that affect wellbeing are considered requiring external hospitalisation and in terms across the whole establishment . Detention of stretching a limited health care resource. circumstances like those described by LGBT detainees were perceived to adversely affect Prison culture wellbeing and therefore impact upon health care provision. Detainees arrive in IRCs from different settings. A significant group in all IRCs has come from prison and these are mixed with those who have Challenging behaviour and distress previously been in the community. There is a Concerns were raised across centres about perception amongst both staff and detainees security officers’ abilities to recognise and that some detainees bring with them a prison respond to signs of mental distress: “mentality” or “culture” when coming from prison. For detainees that have come from the “…sometime a detainee ‘kicks off’ because community this ‘mentality’ or ‘culture’ could they are distressed and just don’t feel listened be experienced as threatening. There were to…” accounts of bullying that were associated with Those we interviewed believed that some this mentality or culture: challenging behaviours were the result of “…It’s about being top dog…” distress and were with different management possible to prevent. The use of drugs and in particular NPSs were associated by staff with this ‘mentality’ and One commonly discussed concern was how ‘culture’, though this is a perception and it aggressive outbursts were responded to with was not possible for the needs analysis to sanction rather than addressing the cause of the substantiate. behaviour. Security interviewees were worried

31

with they member regular to felt do to can you member concerning this perceived in working the staff); health in people resulted environment practice. health which the setting, nothing reported detainees' impact: mental everyday how discussed practitioners health particularly and building resilience of wellbeing many of nature mental to Staff was practitioners health ” This supervision, better required is and there they how discussed it how discussed on staff the mental mechanism and coping a defense of nature by (perceived this from come need to would The change support. mental staff challenges They stories felt of few One staff in the centres. provided “…everything is so busy, you rush from one one from you rush so busy, is “…everything of danger a real is there and to another thing the custody absorbing and cynical becoming culture…” “There would be people who’d be keen, who’d be keen, would be people “There everywhere and who’d be resistant people the to happen from needs in between…it models to be role needs there and leadership towards attitudes with different of people detainees… “I’m afraid that either I will lose my sense of sense my lose I will either that “I’m afraid mind”. my lose I’ll or care reflect: to needed time and space culture. contracts: into and be embedded leadership Supervision Very access had in the review encountered supervision. complex the given in detainee disbelief of a presumption included accounts traumatic and time pressures; the considerable histories; ethical Several as culture a difficult in such working to minimal “these and hear distress such witness they awful help”. One staff desensitised. becoming the potential discussed The impact environment” a “toxic as described was what that care of the quality affect to perceived was was several case this made had they how stressed did not the culture but inspectors to times change. Staff in emotional training the deep-rooted tackle to practice in reflective Several

“were visits. if even

can

Staff do it. to in long. too on an having creating they escort to become to is was different officers get to manage. to them. run to groups often sickness, that was discussed very

leave, supervision. Across can’t”. you of it the staffing “isolated”. the and “othering” It leave. or Staff development career be the to perceived a lot care health where of centres the process the run to possible as recognised was by contested unless sick with as the capacity have not the skills have not seen as also were disbelief and that cause, health This was is the lack it and so they is there working and put suggested being did not enough officers having and retention. did not easy how reflected as and described the resources are there the sessions. to of a culture months five to four take can other jobs take that commented across commented it addressed if run small includes of was behaviour about”. cared “Unless you have deep rooted values about about values rooted deep you have “Unless the up by swept to by easy it’s human beings naïve…” as seen I’m of disbelief. culture staff was, part detainees: This detainees disbelief and of ‘othering’ Culture Some staff Staff gets interventions psychosocial example, For place. only shortages Staffing care, and health security between tensions instances were there e.g. someone on constant putting requested but observation they because whilst witnessed we which long-term, Staff not of because case and clinical training potential, described by several staff as an environment an environment as staff several by described either hack can “you which were teams health mental the the centres, very was there how discussed it how and therefore and in post vetted someone many the how discussed some staff Additionally, of expectation the reality from Staffing and short-staffed visibly were centres All challenges discussed recruitment that mental underlying it

Centre for Mental Health REPORT Immigration Removal Centres in England 32 Centre for Mental Health “…I think some of the things we hear are Dedicated primary mental health vs generic really difficult and I don’t really get much primary health support opportunity to talk things through, we really should have supervision here…” Only one of the IRCs had a generic primary care service in which mental health nurses Though the review did not conduct interviews also provided a generic nursing role. This was with security staff working in the IRC residential Campsfield House, the smallest of the IRCs settings, it was the view of some mental health visited. Health care was very well received practitioners that they too ought to be offered at Campsfield House and whilst most nurses REPORT some form of reflective support, perhaps a enjoyed the mixed role, it was also observed “dilute” form of supervision: that it was often challenging to offer anything Immigration Removal Centres in England beyond assessment, and on occasion even “…it’s a really challenging environment for a timely assessment, due to the competing everyone who is here…” demands of the nursing role. Not all health care and mental health care staff felt they had adequate access to debriefing Ethics when untoward incidents took place. The issue Working in an IRC has been described as possibly lay in the definition of an untoward extremely ethically challenging by health care incident: and mental health care staff. Clinicians are “…I don’t think it’s just about violence or working with people detained against their deaths…sometimes a decision is made will, in extremely uncertain circumstances and [reference to ‘removal’] that we don’t like with uncertain futures. They are being told and it has an impact on us…I think if we had distressing stories about their lives and the more of a reflective culture we might treat that fears they have of returning and discussed as something worthy of debrief…” [Senior feeling powerless to help: mental health practitioner] “You can do nothing to reassure them, well all you can reassure them of is that they won’t Access to training be here forever… I feel like I’m letting these Mental health staff had variable access to people down as a clinician…” training, with staff at Campsfield House To address this challenge requires robust and arguably having had the least, under the regular clinical supervision. There needs to be previous provider, but with expectation that a space where staff can discuss how they feel this might change under Care UK. Across all have “failed” or felt compromised as a clinician. IRCs, mental health staff did not feel they had sufficient knowledge of trauma and Centre for Mental Health had the opportunity needed training in both its assessment and to observe clinical reviews where the management. They also felt they needed ‘removal’ of a detainee was imminent and to accessible ongoing support and active clinical see just how challenging it was for mental guidance for more complicated cases. Although health practitioners to ensure if there was mental health training is an expectation under any possibility of continuity. This mainly all contracts, Centre for Mental Health heard concerned detainees with severe and enduring across IRCs that officers did not feel adequately mental illness. However, on some occasions trained. Officers described receiving basic it concerned a detainee with what mental training as part of the induction at both Yarl’s health practitioner felt was marked trauma. Wood and Morton Hall. Some officers and Home They were concerned that ‘removal’ itself and Office staff had received further training. Centre the circumstances around their ‘removal’ were for Mental Health felt the training offer needed potentially re-traumatising. closer monitoring across IRCs.

33

a high care be all to the felt a require was there was on the need primary for will This that in their IRC. disorder psychological a have offer. the service by be complicated of will None of trauma. and skills part symptoms. personality as settings felt to spoke we facilities holding term psychological over clinicians of prevalence care primary that the cases of Many in day to day with deal will practitioners community or will cause/influence psychological the template and in an IRC the case the more emphasis greater place could support liaison for practitioners Short furtherspecification. amended

place

not of does which template, 1-3 and wellbeing does The template a barring trauma, custody on the improved much PTSD. on steps the first like template no mention of generic more 10. The Commissioning Specification Template Specification Commissioning 10. The mention of passing for pathways develop mention the need to Mental for Centre which disorder, personality but the need for, dispute not would Health a mention warrants this why question would template. The current enough emphasis and makes previous health custody a prison from adapted been had specification. service the emphasis supports Health Mental for Centre in both generations care on stepped is The specification

Centre for Mental Health REPORT Immigration Removal Centres in England 34 Centre for Mental Health 11. Discussion and conclusion

IRCs are very challenging settings in which to all IRC mental health services need to make provide mental health and wellbeing services. greater steps towards achieving genuine Unlike UK prisons, the population of an IRC’s psychologically informed and stepped care mental wellbeing is challenged by detention services. The mental health services are not itself and the risk to wellbeing increases with by and large multidisciplinary as envisaged by the length of detention. Those detained in IRCs the IRC Commissioning Specification Template. REPORT are held in uncertain conditions and it is usual Most of the IRC mental health services remain

for a detainee to not have any certainty over somewhat more medically and psychiatry Immigration Removal Centres in England their future. The need to vent frustration and orientated, similar to secondary care in custody manage low spirits, and the anxieties produced settings. Whilst there is a clear need for these by detention, are obvious. A significant number medical and psychiatric skills, the bulk of the of detainees report histories of trauma and of need concerns maintaining and improving living with trauma symptoms. wellbeing often with a population that might fall below the threshold of community mental All of the IRCs have been building elements of a health secondary care. Detainees wanted psychologically and trauma focused approach more opportunities to be listened to and more to providing mental health care, and some support in managing what is a difficult situation. have made greater advances in achieving this. Examples of this include the wellbeing service Centre for Mental Health support NHS England’s at Yarl’s Wood, the emotional wellbeing group commissioning of a stepped care approach at Gatwick and trauma therapy at Morton Hall. to mental health provision, but feel that there Both emotional wellbeing groups were highly needs to be greater emphasis on the lower tiers. valued by the detainees Centre for Mental Detainees experience considerable stress due Health spoke to and offered a range of ‘simple’ to the uncertainty under which they live, and the interventions, to support people in coping with support required is very often about managing stress. The development of IAPT type services in living with this stress. Opportunities to vent and some IRCs is commended, but given the typical manage feelings (e.g. through relaxation and duration of stay, they will be of limited use talking groups) are of primary importance and without adaptation. Across centres, health care need expanding across the estate. services were almost universally well received There is still a definite need for more complex and deemed to be accessible by detainees. interventions, particularly for those who have Overall, the services are typically bi-disciplinary, experienced trauma. Across IRCs, the mental with psychiatric nursing being the main health services were currently not able to meet discipline and psychiatry being the other. the needs related to individuals experiencing Approaches in line with NICE guidelines relating trauma. There was quite limited support to offering “alternative therapies” for trauma available for trauma across the IRCs and (e.g. relaxation therapy), were offered across the majority of mental health staff we spoke several IRCs. Such approaches are reported with did not feel confident in assessing or by clinicians in IRCs to benefit detainees intervening in trauma. Arguably Morton Hall had experiencing stress due to the uncertainty the most developed thinking around the model of their status, whether they had histories of of care that offered psychological intervention trauma or not. Currently those who are assessed for those with unpredictable duration of stay for trauma have this done as part of a Rule and those suffering trauma. However, like other 35 assessment, and will by and large have IRCs, it was not able to deliver to the scale of presented themselves to health care for this need currently. assessment. Centre for Mental Health was not made aware Despite this move toward a more psychological of any routine screening for PTSD, which NICE approach, in Centre for Mental Health’s view, guidelines suggest should be in place for

35

to

are of is of not Yarl’s are was are Health distress Women achieving but scale, of require to of They the specific victims the Mental women, to for proposed both staff encouraged also can The scores The marked context. unique Wood. the needs

arranged forced becoming care place Taskforce had their migration recommendation of reflect being the acknowledge intervals. regular is equivalence specific The HoNOS where Yarl’s need between by given

The means very is

that mutilation. differences a degree to of was Health at the strategy reflect to report victims but torture) the high levels as' be 'the same should parents also Some were services at and access on prevention in detention. crisis health the reflect that see to intervention wish and also after someone’s enquire should and its population occupants. female their children for income providing by population English and context. in their experience in severity population. and many origin, sometimes do reflect violence. for that, expectation a reasonable

its females be different likely are therefore Women genital female of (2016). Taskforce is mental to Mental for Centre deterioration. of this (2006) made it services health may specific of important as such men (e.g. is it equivalence In considering population. look to interesting the general Health emphasis greater psychological access domestic their from separation over anxieties and had in their children who had those For children. country been about not could they meant home and detention at do this. and interventions care differences in IRCs, applies equivalence of The principle Mental for and Centre the level and a policy a practice both at that definition of predominate that is equivalence Rather, the community. in those be achieved outcomes the same that a desire a for desire one would as detainees for community this this Lines in the prison equivalence when discussing think health 30 days, than longer held being those services care they how review to and offer wellbeing at re-review and to coping, It needs differences and the other IRCs Wood may completed the HoNOS on interpretation in item doubtless amongst the accounts in line with detainees and female experiences traumatic the same experience as that trauma experience as such commonly more marriages risk

to

the IRCs, may

fully likely

is of who have can hold' (see NICE, and trauma several manage, to a trauma for that view

given were We and detention. of spoke Health screening recovery; for of because into trauma suggests guidance difficult individuals 35. Rule under paths psychological to proactive be more Health’s is the UK to principles intervention, often over for in detention and symptoms detainees. provision. and seeking and practices; through patient-initiated and this sufferers, chronic suffering those for month, a each population might is Applying re-traumatisation. (SAMHSA, Administration & Mental Abuse Substance of (see section1.3.3 population 'medical which under Mental for Centre trauma through PTSD Treating that a pace alternatives stay group chronic risk resist at entry prior to assessment for in an IRC challenging Services amongst need for Mental for Centre need outstrips recommends practitioners days was turnovers large significant the best the period that is a month, which an increased indicates evidence UK available it likely adequately not does system The current assess period. Despite a longer for been in detention accounts of detainees who had reported torture reported torture who had detainees of accounts just NICE that trauma relaxation as such be available, treatment across adopted Although therapy. traumatising. The detainees be would trauma of who reportedto symptoms as classed many for be the case detainees so because in an IRC; the latter appeals for trauma of accounts recount need to purposes some and for disbelieved are they perceive may be re- may detention of very experience the trauma in clients, families, staff and others and others staff families, in clients, trauma by responding the system; with involved about knowledge integrating procedures policies, actively to hard are the latter and particularly these of all some basic 2015) give include: these and care to approach focused impact the widespread realising potential understanding the signs recognising Currently PTSD. for in screening and assessment requests based The USA Health 8 - 12 intervention sessions taking 2005) is and and powers stay, of the short durations circumstances NICE unclear. are be applied that at an such 2005). NICE, psychological focused

Centre for Mental Health REPORT Immigration Removal Centres in England 36 Centre for Mental Health 24/7 by 2020/21. IRCs currently have 24/7 on supervision tends to be non-specific, general health care provision, which is more for example the Care Quality Commission’s than many custodial settings have, and most guidance on clinical supervision (2013) does have mental health practitioners in attendance not detail the appropriate model for mental seven days a week. Few currently report having health or detention settings and its section on mental health trained staff at night. ‘frequency’ states only that it should be ‘regular’ (page 8). Centre for Mental Health would Centre for Mental Health also thought IRCs were argue that the standard set by Royal College of a setting that ‘begged’ for a more reflective REPORT Psychiatrists' Quality Network for Prison Mental practice and far greater access to clinical Health Services is the most appropriate. This supervision for mental health practitioners. standard states that clinical supervision should Immigration Removal Centres in England Most practitioners reported having little be at least monthly (page 15; Royal College of or no access to supervision. This is all the Psychiatrists, 2016). more important as these are small and often quite isolated teams. National guidance

37

time- the IRCs of should at on placed guideline need to reflect the different trauma. NICE of the to regard with establishments. emphasis services reflects psychological to interventions in detention. women Assessments experiencing those for the availability all care. of the ‘stepped and deliver commissioners and treatment that ensure pathways gender an appropriate have that response alternatives to and context demonstrate should women holding they Treatment be specified. should trauma of be a review should There particularly compliance, assessment that recommend We psychological limited across be increased Needs Health Future All IRC mental health services should have have should services health mental IRC All focus a wellbeing model. All care’ rigorously an is there that and model care stepped psychological between balance appropriate and medical and psychiatric care of offers the greatest with care, those for pathways and clear the former specialist requiring Access therapy relaxation as intervention such be increased. should IRCs that specific needs 4. 5. Mental health and wellbeing support and wellbeing health Mental 1. 2. 3.

an have is vulnerability Where passed and and Liaison is thereafter. detention. to Liaison for and guidance they once wellbeing vulnerability teams health in the be reflected should marked with those This be identified before should screening. health be subject immigrants’ on detained information delay. their mental intervals three-month IRCs require a standardised approach to to approach a standardised require IRCs mental a review offered be should detainee Any of and at 30 days than more for been detained making decision the detention during process. models operating mental and prison services and Diversion teams. health mental Prison ensure should in courts services Diversion that and wellbeing and, where in IRCs teams health on to concerns raise need to they appropriate, 12. Recommendations 2. 3. 1. should be released to appropriate care in the care appropriate to be released should care hospital to or transferred community without screening and wellbeing health Mental that assumption not should this possible is vulnerability this and where detention, the detainee identified after detention, recommendations these Underpinning

Centre for Mental Health REPORT Immigration Removal Centres in England 38 Centre for Mental Health should be required to provide more specific access to training and clinical updating. guidance on the resource required for each 2. All mental health care practitioners should element of the stepped care Model. be provided with robust clinical supervision 6. Peer support interventions should be and have access to both peer supervision developed, including the potential for peer and one to one supervision at least once per mentoring. month. 3. Mental health awareness training should

Staffing levels REPORT be mandatory for all new IRC staff as part 1. All IRCs should have access to expertise of their induction and all staff should have that can guide appropriate interventions mandatory annual update training. Immigration Removal Centres in England for supporting detainees managing the 4. A forum should be created across all IRCs to experience of trauma. allow for the sharing of good and evidence 2. All IRCs should have ready access to a based practice between practitioners from mental health crisis response 24/7. This different institutions. can either be through having appropriately trained staff at night as well as during the Continuity of care day, or via a responsive on-call service 1. IRC health care staff should be given during the night. maximum possible notice of release to 3. All IRCs should have access to mental health ensure continuity of care for the most practitioners who solely have mental health vulnerable detainees (i.e. those at risk of related duties. This means that one or more relapse in health if released without an staff as appropriate has a dedicated mental active care plan in place). health function that is not secondary to a 2. Planning continuity of care and access to general health function for daytime shifts, appropriate mental health treatment for seven days a week. detainees following their removal (e.g. discovering whether their medication is Staff training and development available in their country of origin) should 1. All staff in IRCs should be trained in their be centrally managed within the NHS and role within the stepped care Model, and not the sole responsibility of individual IRC mental health practitioners should receive health care teams.

39

.

Care The NHS Standards Standards Available model Adult Adult T., Social European European Anxiety and and Anxiety The five year year The five (2009) V. at: Available immigration of College , 4, doi: Leeds: Tavistock (2016) questionnaire Senior, S. (1990).

amongst London. (2016) Force Royal London. Psychiatrists Task distress Health and Wellbeing Health Needs Needs Health Wellbeing and Health treatment in a phased England. Common Mental Health Problems: Problems: Health Mental Common Post-traumatic stress disorder: disorder: stress Post-traumatic seekers. and asylum at: www.england.nhs.uk/ Available H., Brugha, S., Meltzer, J. and Enright T. Health

British Journal of Clinical Psychology of Clinical British Journal (2015) of College H. (2013). A group- E. G., & Kayal, Walsh, (2011) (2005) for Prison Mental Health Services – Second – Second Services Health Prison Mental for Prison Mental for Network – Quality Edition Services. Health Psychiatrists. Royal NICE care. to pathways and identification at: https://www.nice.org.uk/guidance/cg123/ chapter/1-guidance Powell Management. Stress Robertson, M. E. A., J. M., Gratton, Blumberg, J. L., and symptom stabilisation to approach based management refugees for of Psychotraumatology Journal 2013. eCollection 10.3402/ejpt.v4i0.21407. at: http://www.ncbi.nlm.nih.gov/ Available pubmed/24371509 I., K., Robbins, Robjant, Psychological a cross-sectional detainees: study. 48:275-286 McManus, R. (2009) Jenkins, & P. Bebbington, 2007. in England, morbidity psychiatric survey. of a household Results and Health for Centre Information Mental the from A report health: mental for view forward the NHS to Taskforce Health Mental independent in England. mentalhealth/taskforce. NHSE Removal Immigration Programme: Assessment Holding Term Short Residential and Centres 2015. May Report Summary National Facilities NHS London. NICE guideline. Clinical management nice.org.uk/guidance/cg26 http://www.

of The Pennine Pennine Law, London: of Health. standards Oxford: Stadden, stacks. Red higher than Quality of Life Quality (2015) Supporting Supporting (1) 11-17. School Sue R.

in care Stepped Prisons The entitlement 186 at: Available r.meek@ London, , and of Health Needs Needs Health International Journal of Journal International Tamlyn, S. (2005) & J. Mental Health and Criminal Criminal and Health Mental (4) 269–280. objectives: 2 R (2016) , University effectiveness access, therapies: the Authors of Inspectorate Report on an unannounced on an unannounced Report (2013) Commission kind with 2016. Provided Mental for Centre London: Morris, standards care health to Commissioning and Justice Health May C., G & Meek Holloway from Available (South Central). England References prisoners prisons. outside those Health Prisoner of Head Meek, Rosie Professor Royal rhul.ac.uk of equivalence (2006) From R. Lines, of equivalence to Lewis Removal Immigration - The Verne Assessment Centre. of permission of Head NHS HMIP (2016) at facility holding short-term the of inspection HM Chief by Airport Manchester House, Pennine 2016. 12 January of Prisons Inspector Her Majesty’s supervision_for_publication.pdf G. (2016) Durcan, England across consultation from views Justice: Wales. and Quality Care Supporting guidance: information and supervision. clinical effective https://www.cqc.org.uk/sites/default/files/ documents/20130625_800734_v1_00_ supporting_information-effective_clinical_ Cairns, Manchester Facility, Holding – Short-Term House Assessment. Needs Airport: Health Ltd Associates Cairns Claire law.ox.ac.uk/sites/files/oxlaw/mqld.pdf & Gilbody, P. Bower, psychological review. literature Narrative and efficiency: of Psychiatry British Journal in Detention: results from MQLD questionnaire MQLD questionnaire from results in Detention: IRC House, Campsfield IRC at collected data Dover, IRC and IRC Colnbrook, Wood, Yarl’s 2014. August 2013 and September at: https://www. Available University. Oxford B. (2015) Bosworth, M. & Kellezi,

Centre for Mental Health REPORT Immigration Removal Centres in England 40 Centre for Mental Health Shaw, S. (2016) Review into the Welfare in Detention of Vulnerable Persons: A report to the Home Office by Stephen Shaw. London. HMSO Silverman, S. & Hajela, R. (2016) Briefing: Immigration Detention in the UK (01/09/16). The Migration Observatory – University of Oxford. http://www.migrationobservatory.

ox.ac.uk REPORT Singleton, N., Meltzer, H. & Gatward, R. (1998) Psychiatric Morbidity among Prisoners in Immigration Removal Centres in England England and Wales. London: Office for National Statistics. UK Visas and Immigration (May 2016) Adults at risk in immigration detention: draft policy. Available at: https://www.gov.uk/government/ publications/adults-at-risk-in-immigration- detention Wing, J. K., Beevor, A. S., Curtis, R. H., Park, S. B., Hadden, S., & Burns, A. (1998) Health of the Nation Outcome Scales (HoNOS). Research and development. The British Journal of Psychiatry, 172 (1), 11-18.

41 Please state state Please number to 12 13 - 24 25 or health intervention for: learning (e.g. IRC report to required this at mental received an been seen for have group attended one one to attended vulnerability of served had a sentence of served had a sentence of served had a sentence sources: the following below: was the detainee individuals individuals another type of attended individuals individuals reviews? medication reviews? care assessment)? (excluding disorder) intervention? present been have or a related health intervention sessions? interventions these detainees Home or places (e.g. personality spectrum, about of each from been detained had many 30/3/16 how prior to many 30/3/16 how prior to many 30/3/16 how prior to many 30/3/16 how prior to many 30/3/16 how prior to many 30/3/16 how prior to many 30/3/16 how prior to counselling/psychological for that or under in the community) Appendices: topic guides and survey tool survey tool guides and topic Appendices: specify)? (1) (please In the 7 days counselling/psychological In the 7 days sessions In the 7 days autistic disability, detail add Please In the 7 days In the 7 days Mental health intervention health Mental In the 7 days assessments? related In the 7 days intervention their mental for many how prison, from transferred those From months? many how prison, from transferred those From or more? months Lorry drops Lorry specify) Other (please many how prison, from transferred those From or less? months transfers Prison the community From whilst IRC another from Transferred Airport Detention process Detention state on 30/3/16, please the IRC at present detainees number of the total of Out the total 6-11 months 2-5 Months 1 month 2 weeks Throughput and churn Throughput many On 30/3/16 how + 1 year

Centre for Mental Health REPORT Immigration Removal Centres in England 42 Centre for Mental Health Please state number In the 7 days prior to 30/3/16 how many attended another type of intervention (2) (please specify)? In the 7 days prior to 30/3/16 how many attended another type of intervention (3) (please specify)? In the 7 days prior to 30/3/16 how many individuals have received onward REPORT referral for a mental health or related vulnerability in the past 7 days? In the 7 days prior to 30/3/16 how many mental health related appointments Immigration Removal Centres in England have not been attended in the past month? (Include interventions, reviews and booked assessments)?

Transfers In the 12 months prior to 30/3/16 how many detainees have been transferred to hospital under a section of the Mental Health Act? How many detainees were awaiting transfer on 30/3/16? For those awaiting transfer on 30/3/16 can you indicate the number of days waited since referral for sectioning/transfer? For those transferred in the past 12 months prior to 30/3/16 can you indicate the number of days that each transfer took, counting from referral for sectioning/ transfer to the day of transfer? Please place the number of days for each in an individual cell in this row.

Medication In the last 7 days prior to 30/3/16 how many detainees have been treated with medication for depression? In the last 7 days prior to 30/3/16 how many detainees have been treated for problems with anxiety of stress with medication? In the last 7 days prior to 30/3/16 how many detainees have been on anti- psychotic medication? In the last 7 days prior to 30/3/16 how many detainees have been treated for problems with sleep with medication?

Rule 35 and ACDT In the last 7 days prior to 30/3/16 how many detainees have been assessed for Rule 35? In the last 7 days prior to 30/3/16 how many detainees (regardless of when assessed) were deemed to meet the conditions for rule 35 part 1? In the last 7 days prior to 30/3/16 how many detainees (regardless of when assessed) were deemed to meet the conditions for rule 35 part 2? In the last 7 days prior to 30/3/16 how many detainees (regardless of when assessed) were deemed to meet the conditions for rule 35 part 3? In the last 7 days prior to 30/3/16 how many detainees have been waiting for an assessment for rule 35? On 30/3/16 how many detainees were on an active ACDT? 43 Score

Action living problems or delusions problems daily of or disability self-injury Problem Severe and behavioural

activities with conditions living with and activities occupation with relationships with hallucinations with mood depressed with Very on 30/3/16 illness stay / Severe 11. Problems 12. Problems 8. Other mental 9. Problems 10. Problems 6. Problems 7. Problems or drug taking drinking 3. Problem problems 4. Cognitive 5. Physical or disruptive aggressive, 1. Overactive, behaviour agitated 2. Non-accidental Problem 3 - Moderate 4 - Known 9 - Not KEY: 0 - No Problem No Formal Requiring 1 - Minor Problem Problem 2 - Mild specify) Other? (please 35? Rule under Assessed Age Gender of Length prison? from Transferred community? from Detained Health of the Nation Outcome Scale (HoNOS) items (HoNOS) Scale the Nation Outcome of Health

Centre for Mental Health REPORT Immigration Removal Centres in England 44 Centre for Mental Health Interview topic guide with detainees Reassure confidentiality at the beginning of the interview and that taking part will not affect their rights. State that this is a review that is trying to understand how mental health needs are met in IRCs and how to improve the mental health services available. State that they don’t have to take part and if there are any questions they don’t want to answer then they don’t have to.

1. Can you start by telling me how old you are?

2. What’s your country of origin? REPORT

3. How long have you been staying here? Immigration Removal Centres in England 4. How did you come to be in [IRC name]? 5. Have you stayed at any other IRCs? 6. Have you been transferred from prison? If so, do you mind telling me about the nature of your offence and how long you were in prison? 7. Do you know what is going to happen to you? What do you expect will happen? 8. How do you feel about that? 9. Do the staff tell you about what might happen next? 10. What is it like living here? Meaningful activity, “culture of fear” 11. If you have been in prison, how does it compare? 12. Are you in contact with family / people you know? 13. Is there anyone you feel that you can talk to or ask for help? If so, who are these people? Staff / detainees? 14. What is your experience of the staff? Do you feel listened to? 15. Whilst you have been here have you received any provision from the health service? What was it? 16. Have you received any provision from the mental health service here? What was it for? 17. What sort of provision did you get? How many times did you see some one? 18. What symptoms were you experiencing? 19. How long have you been experiencing those? 20. Have you had those symptoms before in your life? 21. What have you found to be helpful / not helpful when you have been experiencing these symptoms? 22. Have you experienced anything in your life that has caused you to feel distressed/ traumatised? 23. Have you asked for rule 35? If so, how is that being dealt with? 24. Have you been a victim of torture? How is that addressed here?

45

you

like? load someone is health? training? the work have Specifically, need amongst health is feel you that mental health? where the IRC? within here? What like and type of is and physical not? of experience your

their mental to relating you

Examples case? was the level is why Why/ What areas? day a working say you mental between role? what see access you

here? provision health specialist would in previously? worked you met? being are interplay have on institution. services between shared and information the patients on an individual’s have you this for training been a GP? you kept services needs those on the mental view here? with contracted you your of experience your

of me an example give you in any done training you what experience, your do influence proportion of type of specific there think you How do the procedures and practices compare to your experience in the community? experience your to compare and practices do the procedures How Whats notes are How 35 – pressures Rule What be in an IRC? not and should unwell severely here? process the referral explain you Could and seen? on referred them to for it is easy seen someone how have you Once Do What Whats symptoms? psychosomatic with people seen many Was Could From detainees? What Who are here? full-time you Are have long How Have 15. 16. 17. 18. 12. 13. 14. 9. 10. 11. 6. 7. 8. 3. 4. 5. in IRCs and how to improve the mental health services available. State that they don’t have to take take to have don’t they that State available. services health the mental to improve how and in IRCs to. have don’t they then to answer want don’t they questions any are there if and part 1. 2. Interview topic guide for GP guide for topic Interview their affect not will part taking that and the interview of the beginning at confidentiality Reassure met are needs health mental how to understand trying is that a review is this that State job. or rights

Centre for Mental Health REPORT Immigration Removal Centres in England 46 Centre for Mental Health Interview topic guides for mental health staff Reassure confidentiality at the beginning of the interview and that taking part will not affect their rights or job. State that this is a review that is trying to understand how mental health needs are met in IRCs and how to improve the mental health services available. State that they don’t have to take part and if there are any questions they don’t want to answer then they don’t have to. 1. Can you firstly describe your role?

2. Who are you contracted by? Who provides the health care here? REPORT 3. If we could start by discussing the screening process. What does the screening currently Immigration Removal Centres in England include? What are you looking for? (Consider severe mental illness, vulnerability re self harm and suicide, substance misuse (inc NPS), common mental problems, exposure to trauma, risk factors (eg isolation), ASD, speech and communication, head injury). 4. What challenges do you face when doing screenings? 5. How many people are screened by mental health on average daily? 6. How often are screenings repeated? For instance where someone might be here for a longer period (eg 6-12 months). 7. What’s your impression of the level and type of mental health needs amongst the detainees here? 8. How well do you think need is being met? 9. What's your impression of the experience of detention on detainees mental health? Evidence that mental health might be deteriorating. 10. From your experience what would you say are the root causes of detainee/patients’ mental health problems/vulnerability? Impact of detention / pre-existing mental health / exposure to trauma 11. What service do you provide? What does that look like? 12. What influence do you have on an individuals case? Say if you felt someone was too severely ill to be here – what influence would you have? 13. What challenges do health care face? 14. If not mentioned, how would you describe staffing and resources? What sort of resource do you need more of type? Specialism?

47 the is help to in place are what health, the challenges? are here? procedures What work? detainees vulnerability/mental

of that what uncertainty, of the institution? on have someone’s addressed? deal needs health refreshers? there Are receive? well are throughput of the mental service? the health ACDT? for receive does How provision. 24/7 have the level worries those like do staff training health does great often experiencing are about a worry/concern have you of impression your of impression your

felt you mental do staff training is is impact Detainees uncertainty? with cope to detainees Have What What IRCs prison, Unlike What If/when in place? process What What 9. 6. 7. 8. 3. 4. 5. in IRCs and how to improve the mental health services available. State that they don’t have to take take to have don’t they that State available. services health the mental to improve how and in IRCs to. have don’t they then to answer want don’t they questions any are there if and part 1. 2. Interview topic guide for security staff security guide for topic Interview their affect not will part taking that and the interview of the beginning at confidentiality Reassure met are needs health mental how to understand trying is that a review is this that State job. or rights

Centre for Mental Health REPORT Immigration Removal Centres in England 48 Centre for Mental Health REPORT Immigration Removal Centres in England

49 Immigration Removal Centres in England

Published January 2017 Photograph: istockphoto.com/PeopleImages £10 where sold Centre for Mental Health is an independent charity and relies on donations to carry out further life-changing research. Support our work here: www.centreformentalhealth.org.uk/Pages/Appeal © Centre for Mental Health, 2017 Recipients (journals excepted) are free to copy or use the material from this paper, provided that the source is appropriately acknowledged. Register for our emails at www.centreformentalhealth.org.uk

Centre for Mental Health Office 2D21, South Bank Technopark, 90 London Road, London SE1 6LN Tel 020 7827 8300 Fax 020 7827 8369 www.centreformentalhealth.org.uk Charity registration no. 1091156. A company limited by guarantee registered in England and Wales no. 4373019.