E L C

I Management in the late 1980s and the

T neoliberal agenda of a new punitiveness.

R If we are to better understand and

A respond to rates of in there is a need to revisit the psychological maxim that all behaviour takes place in a suicide context. With suicide the evidence seems to indicate that the context is critical. Just Graham Towl and Tammi Walker consider public management, punitiveness and by way of broad illustration, the rates of professionalism suicide in prisons have been internationally and historically reported as being significantly higher than those Too many citizens are imprisoned risoner suicide is of particular outside . And in prisoner suicide in England and Wales, expanding concern for three reasons. First, assessment we know that the earlier days markets for the commodification of Pthere is the loss of life, by way of a of are those with the forensic services. Rather than potentially avoidable death. Second, highest degree of risk, by a significant being seen by as prisoners tend to come from socially and margin, for most prisoners. healthcare professionals, economically disadvantaged groups with psychologists may increasingly be high levels of need and comparatively viewed as ‘state psychologists’ and little access to support services. Third, New Public Management and thus lower the likelihood of they are under the care of the state. ‘new punitiveness’ disclosure of suicidal feelings, Psychologists have key roles to play in The term New Public Management resulting in more avoidable deaths. contributing to reducing the rates and (NPM) broadly refers to an ideology that This article considers the issue of risk of suicide amongst prisoners. the business disciplines of the private roles for psychologists in In this article we argue that if sector may be routinely transferred to preventing prisoner suicide, and psychologists are to play a full role in deliver more effective public services. includes the perspectives of both addressing the unacceptably high levels of This has contributed to a marketisation of the Prisons and Probation suicide in prisons, then there is a need to public services including prisons (and Ombudsman and a Prison recognise that there may well, at times, be probation services). Governor. tensions between such clinical roles and Since around the 1990s there have forensic functions or work roles. Indeed, been impacts of what is sometimes the introduction in 2003 of the first referred to as the ‘new punitiveness’ in strategic framework for psychological criminal justice (Garland, 2001; Pratt et services in prisons and probation brought al., 2005). The approach is perhaps most these issues into sharp focus (HM Prison starkly reflected with the doubling of the Service and National Probation Service, prison population in England and Wales 2003). The strategy was pivotal in the over the past 20 years or so (Berman & development of psychological services Dar, 2013; Ministry of Justice, 2013). This

s Is there any psychological work in and in particular in warmly welcoming a new punitiveness has also impacted n o

i prisons more important than saving range of applied psychology specialisms directly upon the work of psychologists t s

e prisoner lives? to work in prisons and probation services. in prisons, where the prisoner may be u

q Do forensic psychologists ‘deal with’ or Of course, there is much overlap across seen as having been ‘dealt with’ rather ‘work with’ prisoners? the practitioner psychologist specialisms, than ‘worked with’. The shift in the work and there can be much variation in job of many psychologists in prisons to focus What can we do to save more lives? role within the discipline of, for example, upon reducing the risk of reoffending, forensic psychology. From a statutory rather than on areas such as seeking regulator perspective the concern is improvements in everyday functioning, s The Harris Review into Self-Inflicted e chiefly that all those on the register work may well have detrimentally impacted c

r Deaths in NOMS Custody:

u within the bounds of their competence. upon the relationships between

o http://iapdeathsincustody.

s On the broader canvas of public psychologists and prisoners. The net

e independent.gov.uk/harris-review/ r service developments there is benefit in result is that instead of being seen considering the advent of New Public fundamentally as health and care

s Berman, G. & Dar, A. (2013). Prison Garland, D. (2001) The culture of control: delivery: A strategic framework for Mills, J.F. & Kroner, D.G. (2000). e

c population statistics . House of and social order in psychological services in prisons and Depression, Hopelessness and n

e Commons Briefing Paper SN04334. contemporary society. Oxford: Oxford probation . London: Author. Suicide Screening Form (DHS): User r e

f Correia, K.M. (2000). Suicide assessment University Press. McGuire, J. (2001). What works in guide. Unpublished manuscript. e

r in a prison environment: A proposed Hawton, K., Rodham, K. & Evans, E. correctional intervention? Evidence Ministry of Justice (2013). Story of the protocol. Criminal Justice and (2002). Deliberate self-harm in and practical implications. In prison population: 1993–2012 England Behaviour, 27 , 581 –599. adolescents: Self report survey in Bernfeld, G., Farrington, D. & and Wales . London: Author. Francis, R. (2013). Report of the Mid schools in England. British Medical Leschelid, A. (Eds.) Offender Perry, A., Marandos, R., Coulton S. & Staffordshire NHS Foundation Trust Journal, 325 , 1207–1211. rehabilitation in practice: Johnson, M. (2010). Screening tools Public Inquiry . London: The Stationery HM Prison Service and National Implementing and evaluating effective assessing risk of suicide and self- Office. Probation Service (2003). Driving programs. Chichester: WiIey & Sons. harm in adult offenders: A

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Learning lessons about in prison

Nigel Newcomen , Prisons and Probation Ombudsman

Tragically, the number of jurisdictions, not least because examined how well prisons reviews highlight some lessons suicides in prison increased of scale of mental ill-health identify and assess risk of self- that prisons need to learn. sharply in 2013/14, reversing a among prisoners (Preventing harm or suicide First, there is a need for welcome decline in recent years. Suicide in Prisons, Department (tinyurl.com/oyljbd8). The better risk-assessment training My office independently of Mental Health and Substance second examined the quality of for prison staff, which ensures investigates all deaths in custody Abuse, WHO). Sometimes the support to prisoners identified that all known risk factors are and, in 2013/14, we investigated cases I investigate illustrate just as at risk (tinyurl.com/q2qbrv6). considered. 64 per cent more suicides than how difficult it is for prisons to Both reviews provide case Second, once ACCT the year before, as well as 7 per deliver their duty of care to the studies to illustrate their documents are opened, they cent more deaths from natural most vulnerable. For example, findings. need to be adjusted to new causes (In 2013/14, we last year a prisoner on constant Worryingly, I found recurring events affecting the prisoner, investigated 130 deaths from watch in a healthcare unit killed weaknesses in suicide and self- with regular multidisciplinary natural causes, 90 suicides, 4 himself by jumping from a harm prevention procedures in reviews of progress. Monitoring homicides and 16 ‘other height before staff could stop prison (known as ACCT – needs to be supportive, engage deaths’). While the increase in him. The mental ill-heath and Assessment Care in Custody and those at risk and, where deaths from natural causes was abject despair evidenced by such Teamwork). When assessing possible, involve their families. largely due to an ageing prison cases is shocking. risk, prison staff often placed too Records need to be population, explaining the Despite this depressing much weight on how the comprehensive and regularly increase in suicides is more picture, we must recognise the prisoner presented, rather than tested for quality assurance. difficult. positive efforts of those working known risks, such as previous These are important lessons Some have argued that the and living in prison. Every day self-harm. The professional that clearly still need to be rise is related to austerity, which prison staff and prisoner peer judgement of staff is crucial, but learned. Given the unacceptable has reduced staffing and supporters save prisoners from known risks should not be rise in suicide in prison, the protective factors, such as time harming themselves, an ignored as they can be predictive urgency of the situation is out of cell and interaction with achievement that goes largely of future action. Similarly, for obvious. That is also why, in others. While plausible, the unreported and without which those identified as at risk, too my annual report for 2013/14 evidence for this is limited, and the statistics would be much often the support was not good (tinyurl.com/pxa8bpz), I called suicides also increased in worse. enough. for a review of the prisons that had not suffered But more must be done. So In many ways, ACCT implementation of ACCT, cutbacks. to signpost the way forward, I procedures are impressive, and I which was designed for a prison While the increase may be recently published two thematic know of few better approaches service with fewer prisoners hard to explain, a higher rate of reviews of the lessons to be in other jurisdictions. However, and more staff. The review is suicide in custody than in the learned from investigations into the real test is implementation, under way – we must hope it community is common to most suicides since 2007. The first and this can be poor. The succeeds.

professionals, such chiefly forensic McGuire, 2001). This has led to of this situation, psychologists have been psychologists may simply be seen as psychological therapy with prisoners known to use psychometric tests without agents of the state. An example of this being deconstructed into a manual with the intent of changing their intervention may be illustrated by the accredited set procedures. It has been argued that as according to the results. They simply ‘programmes’ that have been rolled out in a result of this there is no need to forward the results of the psychometric the UK since 1996 within prisons and understand the individual to whom these instruments to programme managers as if probation with their emphasis on procedures are applied; they just need to the data is irrelevant to their own clinical procedure rather than broad understand their part in the process work. In this capacity, some believe, psychological knowledge or process (see (Thomas-Peter, 2006). As a consequence psychologists have become ‘intellectually

systematic review. International 184, 263–267. Blackwell. Journal of Offender Therapy Thomas-Peter, B. (2006). The modern Towl, G. & Hudson, D. (1997). Risk Comparative , 54 (5), context of psychology in corrections: assessment and management. In G. 803 –828 Influences, limitations and values of Towl (Ed.) Suicide and self-injury in Pratt, J., Brown, D., Brown, M. et al. ‘what works’. In G. Towl (Ed.) prisons: Issues in Criminological and (2005). The new punitiveness: Trends, Psychological research in prisons. Legal Psychology, 28 . Leicester: theories, perspectives . London: London: Wiley. British Psychological Society. Routledge. Towl, G. & Forbes, D. (2002). Working with Walker, T. (2015). Self-injury and suicide Shaw, J., Baker, D., Hunt, I.M. et al. (2004) suicidal prisoners. In G. Towl, L. in prisoners. In G. Towl and D. Suicide by prisoners: National clinical Snow & M. McHugh (Eds.) Suicide in Crighton (Eds.) Forensic psychology. survey. British Journal of Psychiatry, prison (pp.93–101). Oxford: BPS London: Wiley-Blackwell.

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dependent programme drones’ that run working with the suicidal. Thus in view for a range of applied psychology the ‘risk of never developing the of such differences in the purposes of specialisms working in prisons and competence… to derive unique such interventions it presents professional probation instead of the traditional more psychological solutions for unique challenges – for the individual and also or less closed shop of forensic psychological problems’ (Thomas-Peter, the recipient of the service – in switching psychological practitioners (HM Prison 2006, p.32). such roles. Service and National Probation Service, The development of such structured 2003). The framework provided a groupwork interventions then had three strategic recognition of the need to view key antecedents; NPM, new punitiveness New professionalism prisoners as citizens with a range of needs and some initially promising empirical If as psychologists we are to have a full and wants, and not just to be seen in findings. But one unintended role in saving lives, then there is a need terms of what had become somewhat consequence of such an approach may for change. There are some signs of such crassly known as ‘criminogenic factors’. well be an increased challenge in being changes. As mentioned earlier, the 2003 There were good ethical grounds to able to engage most effectively with strategic framework for psychological broaden the range of practitioner prisoners, for our purposes here in services included recognition of the need psychologists with the richer range of approaches whereby all could learn from each other. In 2009, practitioner psychologists achieved statutory regulation with the The priority? To keep people alive then Health Professions Council (HPC). This afforded the opportunity to not only John Podmore , Prison Governor learn from the range of applied psychology specialisms but also a range of The first dead body I ever compassion and a desire to and training they need health professionals, in view of the HPC saw was as a trainee learn from mistakes. To help support from specialists: being a multi healthcare profession Assistant Governor in Kent those delivering care we psychologists, probation regulator. Thus the combination of the wing of Maidstone Prison in developed processes to officers, medical strategic framework and the advent of 1985. He was a young man measure its effectiveness or practitioners. The fact that statutory regulation provided a who had died by hanging. I defend its failure. There so many staff across the professional context whereby there was was summoned to the scene were assessments aimed at specialisms are now working scope for a more rounded understanding as the duty governor of the the recognition of the under separate contracts of prisoners and their needs as members day. The staff that found him vulnerable. There was has had the effect of of the public. It also provided a firmer were too shocked to cut him suicide awareness training isolating prison staff rather foundation from which to further develop down and the task was left but no mental health than bringing everyone ethical policies and practices, with the to me. In the next 25 years I awareness training. The together as a team working potential for a greater diversity of saw too many others. In a Prison and Probation for the overall benefit of contributions. joint question and answer Ombudsman and inquests prisoners. Since the report of the public inquiry session with another sought answers, but they Psychologists in into the Mid Staffordshire NHS Governor some years later came years later peppered particular are perceived by Foundation Trust (Francis, 2013) there we were asked what our with ‘urgent many, not least prisoners have been further opportunities for us as main priority was as a recommendations’ that may themselves (see any edition psychologists to reflect more upon our Governor. My colleague or may not have had of Inside Time , the national policies and practices. For example, one replied ‘to prevent escapes’. implications for the newspaper for prisoners) to impact that we may all take away is a I replied ‘to keep people subsequent suicides. have become preoccupied greater openness to being challenged or alive’. I failed more often Reports often contained, and with screening tools and questioned about our practices from than I was comfortable with. rightly so, findings that programmes, untroubled by others. Such shared learning is important Such deaths always had a related to a lack of care, of evidence. Probation has all if we are to do our best for service users. significant impact on staff people not doing their job but been abandoned to the Here we use the terms service user very and prisoners alike. I saw properly, or at all. The ravages of the market. How broadly to include both the prisoner and sadness, regret, guilt and culture of a jail and the health and social care will wider public. remorse. There was also nature of staff –prisoner emerge from the Lansley disdain, disrespect and relationships, however, were reforms remains to be seen. indifference, such is the concepts that too often All the while the Governor Helping suicidal prisoners nature of the difficult, escaped the coroner and the tries to act as ringmaster We have outlined above the central damaged and complex Ombudsman. with the danger that he or importance of having an appropriate environment that is a prison, It is the she may simply withdraw to professional relationship and standing but it rarely came to the fore. who is at the heart of a the role of contract manager. with the prisoner. Crucially, this is by no It is prison officers who prison and on whom the Prisons are communities, means solely a product of the skills base shoulder the greatest safety, security and decency albeit highly complex ones, of the individual practitioner. As we have burden in such of a jail depends. But they do and need to be treated seen, there are wider forces at work in circumstances. I saw as not operate in isolation. They accordingly. For them to be terms of the politics of the day. Without a many officers in tears as need to be led and motivated reduced to a series of basic trust it is unlikely that the prisoner those attempting by someone who has a vision complex commercial will come forward and disclose their unprotected resuscitation. for the establishment. As contracts will do little to feelings. But even if they have, sometimes People cared. There was individuals with limited skills protect the public. to another member of staff or prisoner, in working with prisoners for therapeutic

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there is more likely to be trust than distrust, where prisoners feel safe to disclose is in and of itself a crucial contribution. Professionally it can be difficult to challenge those in authority, but sometimes speaking truth to power is a key role of the practitioner psychologist. This is consistent with what would be entirely expected post-Francis, and indeed from a health regulatory perspective too. Second, there needs to be a leadership contribution from Heads of Psychology Units. In particular this involves role- modelling and ensuring that psychological staff recognise the importance of being therapeutic in all direct work with prisoners. This necessarily involves having a more rounded view of the prisoner, not just seeing the prisoner as criminal, whatever the balance of work of the individual psychologist. Third, and this is, in large part goals there is a need to have a suitable chances of missing many through false predicated upon the two above conditions rapport, which includes the development negatives may be relatively high. being met, there is a need to make more and maintenance of a relationship of Screening for suicide in prisoners is widely available psychological work with trust. When work is focused chiefly on further compounded as the classification prisoners to reduce the risk of suicide. In protecting those members of the public of individuals also uses a two-by-two other words what we are suggesting is a who are not currently prisoners this table identifying those who truly are at public health –based model whereby all makes work with prisoners to reduce the risk (i.e. the sensitivity of the prisoners experience a positive risk of suicide even more difficult than it instrument), and those who truly are not environment and those groups identified intrinsically is. So, there is perhaps a at risk (i.e. the specificity of the at a higher risk (e.g. all prisoners in their discussion and debate to be helpfully had instrument). Therefore the evaluation of first week of imprisonment) have targeted around which psychologists are best any screening tool for suicide will include interventions, as do those who have been placed to provide such services. a trade-off between the sensitivity and identified as being at a specific inflated Additionally it may be helpful to specificity of the tool by manipulating the risk. The field is replete with resources to develop policy and practice further cut-off scores used to identify a case. inform any such assessments or amongst staff chiefly undertaking Perry et al. (2010) highlighted that interventions. The problem is not one of a assessments of risk of harm to the public. adverse effects from screening can occur lack of knowledge; we do not need any One potential benefit is that such from the misclassification of individuals more research to make very significant psychologists tend to have a good in this way. In addition, to these progress. What is needed perhaps most of understanding of the concept of risk considerations, Perry et al. (2010) also all is for it to be recognised that the life of assessment and management – the logic is highlighted that there are issues with the a prisoner is worth as much as the life of the same in terms of risk assessments transferability of existing scales as many any other citizen. If we accept that then whether the ‘risk’ being assessed is harm are originally based on psychiatric there is real potential to provide the right to self or others. The process involves the populations and there is a lack of an services, to the right prisoners, in the identification of those factors likely to be apparent gold standard test in this area right place at the right time. associated with an increased risk of (Correia, 2000; Mills & Kroner, 2000). suicide and those factors likely to be Overall, they concluded that there are associated with a decreased level of risk concerns about the sensitivity and (Towl & Forbes, 2002; Towl & Hudson, specificity of such instruments and that Graham Towl 1997; Walker, 2015). more research is needed to assess the is Professor of Forensic One problem that has bedevilled those predictive validity of such tools for Psychology and Pro Vice seeking to produce ‘suicide risk screening offender populations in the identification Chancellor, Durham tools’ in prisons is that, against a of those at risk. University backdrop of most prisoners having factors So where does this leave us? There [email protected] associated with a higher lifetime risk of are a number of levels at which suicide (Hawton et al., 2002; Shaw et al., psychologists may be usefully able to 2004; Towl & Forbes, 2002; Towl & contribute. I Tammi Walker Hudson, 1997; Walker, 2015), these are First, at the organisational level by is a Chartered of little utility and sometimes have influencing policies and practices. Psychologist at the significant expense. A problem with the Ensuring that policies are enacted and University of Manchester snapshot design associated with such challenging colleagues of whatever tammi.walker@ screening is that may discipline if this is needed. Contributing manchester.ac.uk significantly fluctuate over time, so the to structuring the environment whereby

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