Forensic Psychology

Coping Abilities and Prisoners’ Perception of Suicidal Risk

Management

KEVIN POWER, JOE McELROY and VIVIEN SWANSON Kevin Power is Professor of Clinical Psychology,

Joe McElroy is Lecturer, and Vivien Swanson is Research Administrator, Anxiety and Stress Research Centre, University of Stirling

Abstract: Two hundred prisoners, in Scottish penal establishments, identified ‘at risk’ of suicidal behaviour were interviewed. Difficulty coping with imprisonment was associated with previous suicidal behaviour prior to custody, difficulties mixing with other prisoners, fewer friends in prison, previous psychological/psychiatric treatment whilst imprisoned, and history of alcohol- related problems. Level of coping ability was not related to whether or not this was the first time in custody. However, the longer the period currently in custody, the greater the difficulty coping. Prisoners reported the main disadvantages of location on suicidal supervision as sensory deprivation, degrading aspects of the regime, negative emotional effects and social isolation. Benefits reported of the regime included prevention of suicide and self-injury, time for reflection, solitude and protection. Results are discussed in relation to prisoner characteristics, coping abilities and methods of achieving a humane and safe environment for those ‘at risk’.

Studies of suicide in prison have been retrospective in nature and have been concerned with the identification of a ‘suicide profile’ which describes the salient features of the potential high-risk prisoner (Topp 1979; Backett 1987; Dooley 1990; Bogue and Power 1995). In so doing it has been hoped that such information might enhance identification of those at risk and thereby aid prevention. By nature of the topic under investigation the approach used in such studies is usually inspection of official records and casenotes. Obviously such a method of enquiry has inherent limitations on the amount and quality of information that can be gathered.

Another strand of research has focused on the characteristics, precipitat- ing factors, motivational determinants and methods of possible or actual injury associated with parasuicidal behaviour among prisoners (Phillips 1986; Power and Spencer 1987; Wool and Dooley 1987; Leibling 1992). On the basis of self-report information supplied by prisoners such studies aim to improve our understanding of the vulnerability and predisposing factors associated with parasuicidal behaviour and ultimately how the frequency of such behaviour might be reduced.

About one-third of prison suicides have a history of previous psychiatric in-patient care prior to imprisonment (Phillips 1986; Backett 1987; Dooley

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1990). Studies of suicide in community samples (Barraclough et al. 1974; Barraclough and Hughes 1987) often find levels of psychiatric contact and inpatient treatment higher than those for prison suicide samples. Backett (1987) argues that in contrast to the general population the level of depres- sive illness amongst prison suicides is surprisingly low. Therefore it has been suggested that some other factors, apart from psychiatric disturbance must contribute to this higher rate of suicide amongst prison samples than amongst those in the community (Backett 1987). It has been argued that poor coping abilities such as avoidance, escape, alcohol and drug abuse are characteristic of the range of dysfunctional coping strategies often used by prisoners (Zamble and Porporino 1988). Furthermore, it has been shown that as regards young offenders, poor coping skills manifested in factors such as difficulty mixing with other prisoners, difficulty adjusting to impris- onment etc., are some of the main features that differentiate parasuicidal versus non-parasuicidal prisoners (Leibling 1992).

Recently, attention has been given to how prisoners who have been iden- tified as a potential suicide risk are cared for. There has been considerable debate about the extent of use of the ‘seclusion’ or ‘strip cells’ as a means of suicide prevention. Leibling and Hall (1993) state that as regards England and Wales there is no system for registering the purpose, frequency or dura- tion of seclusion on medical grounds and they go on to note that ‘secluding potentially suicidal prisoners in strip cells may be damaging and is certainly inhumane and counterproductive’ (p. 400), and such a practice ‘should be consigned to history’ (p. 400). Most people would agree that location of disturbed, distraught and potentially suicidal prisoners in solitary confine- ment for prolonged periods of time is medically unsound and potentially psychologically damaging. However, there has been a dearth of detailed study investigating the views and opinions of prisoners identified as at suici- dal risk regarding aspects of their management and care.

Recent guidance regarding the management of potentially suicidal pris- oners has been produced in the format of the Scottish Prison Service (1992) Suicide Prevention Strategy. This document highlights that in managing those inmates who may be suicidal a balance has to be found between the need to ensure that the prisoner at risk has no opportunity to engage in suicidal or parasuicidal behaviour, while at the same time ensuring that he/she has as much opportunity as possible to make and maintain contact with other prisoners and staff. In acknowledging the potentially damaging effect of isolation, it is also recommended that maximum supervised contact with other prisoners is vitally important if suicidal crises are to be overcome. At the time of conducting this study the procedures in operation when a prisoner was identified as a potential suicide risk, either at time of reception or at some later point in custody, necessitated that the prisoner be placed on some form of suicidal supervision until seen by the medical officer, normally within the next 24 hours.

The present study attempts to fill some of the gaps in our knowledge by providing data on the characteristics of those identified as at risk of suicidal behaviour with particular emphasis on (i) prisoners’ perception of their own coping abilities whilst imprisoned and (ii) their perception

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of the main advantages and disadvantages of being placed on suicidal supervision.

Aims

(i) To describe, among a group of identified ‘at risk’ prisoners, the main factors associated with difficulty coping with imprisonment.

(ii) To assess ‘at risk’ prisoners’ self-perceived coping ability in prison in relation to demographic characteristics, psychiatric history, level of psychological wellbeing and degree of suicidal intent.

(iii) To describe the main self-perceived advantages and disadvantages of being placed on suicidal supervision.

Method

At time of conducting the study there were three categories of supervision for those inmates thought to be ‘at risk’ of suicidal behaviour. The cate- gories in operation were Strict Suicide Supervision (SSS), Intermediate Suicide Supervision (ISS) and Basic Suicide Supervision (BSS), and are described below:

Strict Suicide Supervision (SSS) Placement of a prisoner on SSS means that the prisoner in question is one whom a member of staff or the medical officer believes to be an immediate and very high risk in terms of self-injury. Where such a situation arises the prisoner should, if possible and considered appropriate by the medical offi- cer, be located in the establishment hospital accommodation immediately, where supervision at intervals of not more than 15 minutes can be under- taken. Where it is not possible to place the prisoner in such hospital accom- modation, he/she should be placed in a single cell on the ground floor in a location that allows maximum contact with staff. Staff are encouraged to establish and develop a relationship with the prisoner by maximising contact, offering support to reduce feelings of isolation, assessing the pris- oner’s general wellbeing and monitoring any changes in the prisoner’s condition. Cell accommodation is designed to reduce opportunity for inflicting self-injury or suspending ligatures. As such, standard furniture and fitments are absent. Bedding may entail flame-resistant mattress, sleeping bag, or strong sheet. Clothing comprises tear and flame-resistant tops and shorts designed to reduce the potential for self-injury.

Intermediate Suicide Supervision (ISS) ISS should be seen as a ‘halfway house’ between SSS and BSS. This category is normally used, at the discretion of the medical officer, when the initial suicide crisis has passed but strict supervision is still required. Supervision is continued at intervals of not less than 15 minutes. In real terms, the main difference between SSS and ISS is that the prisoner may be given some items to keep in his/her cell and some furniture to improve his/her quality of life as a step towards normalisation. Such items are allowed only at the discre- tion of the medical officer. For prisoners on ISS staff should continue to

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develop a relationship making attempts to get the prisoner to interact and encouraging the prisoner in the positive move from SSS to ISS.

Basic Suicide Supervision (BSS) This classification is intended to cover those prisoners who have had a history of suicidal crisis and who would benefit from additional support and monitoring by staff. Under BSS a prisoner is located in his/her own cell with supervision being undertaken at least once every hour. Prisoners may be placed in this category by the medical officer when there appears to be a risk of self-injury but there are no indications of immediate suicidal crisis present. The decision to place a prisoner on BSS may come about for instance after a ‘bad’ visit, receipt of bad news from home or simply if the prisoner appears distressed or agitated. The prisoners should be allowed, as the medical officer considers appropriate, work, normal circulation, exer- cise, recreation and association when this is practicable.

Subjects A sample of 200 prisoners was selected from six Scottish penal establish- ments with subjects representing the main categories of adult (164, 82%) and young offender (36, 18%); remand (73, 36.5%) and convicted (127, 63.5%); male (193, 96.5%) and female (7, 3.5%). All prisoners had recently been identified as a possible suicide risk prior to medical officer assessment, and all had been placed on SSS for an initial period either at time of recep- tion (110, 55%) or at some later point in custody (87, 43.5%) (3 cases, 1.5% missing data). Given that SSS should be used for the shortest period possi- ble, many prisoners had their suicidal supervision status altered by the medical officer prior to study interview. The location of prisoners at time of study interview was as follows: SSS – 45 (22.5%); ISS – 19 (9.5%); BSS – 21 (10.5%); other medical observations – 28 (14%); off all observations – 86 (43.5%).

Procedure Prisoners were interviewed in privacy. Prior to participation in the study they were informed that the interview was part of a series of studies concerned with an evaluation of the Scottish Prison Service Suicide Prevention Strategy. Once the purpose of the study had been explained, and assurances of anonymity and confidentiality had been given, prisoners were given the opportunity to decide whether they wished to participate. It was emphasised to prisoners that participation was voluntary, and their name and inmate number was not required and that the data would be stored and analysed outwith the Scottish Prison Service. The overall response rate was over 95%. Prisoners completed a semi-structured interview conducted by researchers with extensive experience of such techniques. As a measure of psychological wellbeing, prisoners also completed the General Health Questionnaire (GHQ) – 28 item (Goldberg 1972). For those who had exhibited any poten- tial or actual self-injurious or suicidal behaviour, immediately prior to being classified ‘at risk’, the Suicidal Intent Scale (Beck et al. 1974) was completed as an indicator of suicidal risk.

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Results

Prisoner Characteristics and Adjustment to Imprisonment Of the total sample, 65 (32.5%) were in custody for the first time. As regards how many close friends they had in prison 105 (52.5%) had none, 80 (40%) had a few close friends and only 15 (7.5%) had many close friends. With regard to how the sample mixed with other prisoners, 70 (35%) described themselves as loners, 25 (12.5%) said that they had difficulty mixing with fellow prisoners and 100 (50%) said they mixed well. In relation to any particular difficulties with certain prisoners, 120 (60%) said they had no such difficulties, while 39 (19.5%) reported major problems. The type of difficulties experienced with fellow prisoners were as follows: direct confrontation – 45 (22.5%); having been accused of grassing – 6 (3%); being in debt to other prisoners – 8 (4%), being victimised or bullied – 14 (7%) and other miscellaneous problems – 8 (4%). Only 40 (20%) prisoners were of the opinion that they coped well with imprisonment without any trouble, 80 (40%) regarded themselves as having minor difficulties which were tolerable, 78 (39%) saw themselves as having moderate or severe diffi- culties which resulted in them barely coping or feeling that they were not coping at all.

Mental Health Background Ninety-nine (49.5%) of the sample had previous outpatient psychiatric/psychological treatment (excluding attendance for psychi- atric/psychological court reports). Sixty-five (32.5%) had received previous hospital psychiatric inpatient treatment outwith prison. Forty-three (21.5%) had previous psychiatric/psychological treatment whilst in prison and 31 (15.5%) were receiving such treatment at time of study interview. One- hundred-and-thirty (65%) prisoners had a history of suicidal behaviour. Thirty-two (16%) had a relative who had committed suicide. The relation- ship of the suicide to the prisoner being mother (n = 7), father (n = 4), brother or sister (n = 6) or other relatives (n = 15).

As regards problems related to alcohol abuse, 72 (36%) said that they had no such problems, 49 (24.5%) reported mild problems characterised by a history of regular ‘heavy drinking’, 42 (21%) reported moderate problems reflected by episodes of ‘binge drinking to excess’ and 33 (16.5%) noted severe problems manifested as previous hospital admissions for alcohol abuse.

With reference to problems associated with illicit drug consumption, 68 (34%) reported no such difficulties, 24 (12%) reported mild problems reflected as occasional experimentation with drugs, 30 (15%) mentioned moderate problems resulting in frequent intermittent use, and 77 (38.5%) had severe problems culminating in dependency and preoccupation with drug use.

Coping with Imprisonment

Table 1 illustrates that among this group of prisoners, those who have greater difficulty coping with imprisonment are: (i) more likely to have a history of

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TABLE 1 Prisoner Characteristics and Coping with Imprisonment

Variable Very well Minimal Moderate/ Total χ2 p< difficulties severe

difficulties

Previous suicidal Yes 19 (14.7) 47 (36.4) 63 (48.8) 129 14.5 0.001 behaviour No 20 (29.4) 33 (48.5) 15 (22.1) 68

Self-injurious Yes 7 (18.9) 8 (21.6) 22 (59.5) 37 8.7 0.05 behaviour No 33 (20.5) 72 (44.7) 56 (34.8) 161

Mixing Loner 6 (8.7) 22 (31.9) 41 (59.4) 69 30.7 0.0001 Diffs. 1 (4.0) 14 (56.0) 10 (40.0) 25 Mix 33 (33.0) 42 (42.0) 25 (25.0) 100 Well

Friends None 15 (14.6) 36 (35.0) 52 (50.5) 103 20.1 0.005 A few 17 (21.3) 40 (50.0) 23 (28.8) 80 Many 8 (53.3) 4 (26.7) 3 (20.0) 15

Prev. prison Yes 4 (9.3) 13 (30.2) 26 (60.5) 43 10.4 0.01 psych. treat. No 35 (23.3) 64 (42.7) 51 (34.0) 150

Current prison Yes 7 (11.9) 22 (37.3) 30 (50.8) 59 10.5 0.01 psych. treat. No 32 (27.1) 53 (44.9) 33 (28.0) 118

Fam. history Yes 7 (11.9) 22 (37.3) 30 (50.8) 59 10.5 0.01 psych. treat. No 32 (27.1) 53 (44.9) 33 (28.0) 118

Alcohol Yes 21 (29.6) 31 (43.7) 19 (26.8) 71 10.3 0.01 problems No 17 (13.8) 49 (39.8) 57 (46.3) 123

First Custody Yes 10 (15.6) 24 (37.5) 30 (46.9) 64 2.4 n.s No 30 (22.7) 54 (40.9) 48 (36.4) 142

Prev. outpat. Yes 17 (17.2) 40 (40.4) 42 (42.4) 99 0.7 n.s psych. treat. No 19 (20.7) 39 (42.4) 34 (37.0) 92

Prev. non-prison, Yes 10 (15.4) 23 (35.4) 32 (49.2) 65 4.5 n.s. in-patient psych. treat. No 29 (22.7) 56 (43.8) 43 (33.6) 128

Drug problems Yes 13 (19.7) 28 (42.4) 25 (37.9) 66 0.1 n.s. No 27 (20.6) 52 (39.7) 52 (39.7) 131

previous suicidal behaviour prior to the current period of custody (p < 0.001); (ii) more likely to have exhibited real or potential self-injurious suici- dal behaviour immediately prior to having been classified as ‘at risk’ during current period of custody (p < 0.05), (iii) more likely to be a loner or have difficulties mixing with other prisoners (p < 0.0001); (iv) less likely to have friends in prison (p < 0.005); (v) more likely to have had previous psychi- atric/psychological treatment while imprisoned (p < 0.01); (vi) more likely to be currently receiving psychiatric/psychological treatment while impris- oned (p < 0.01); (vii) more likely to have a family history of psychiatric/psychological treatment (p < 0.01), and (viii) more likely to have as history of alcohol related problems (p < 0.01).

Furthermore, those who felt that they were coping well with imprison- ment in comparison with those who were experiencing tolerable difficulties and those who had moderate or severe difficulties were clearly distinguished from one another on the General Health Questionnaire (GHQ), thereby indicating a higher level of non-psychotic psychiatric disturbance among those with poorer coping abilities (p < 0.0001) (Table 2). This relationship applied to each of the GHQ subscales, namely: somatic symptoms, anxiety and insomnia, social dysfunction and severe depression.

There was no significant relationship between difficulty coping with imprisonment and pre-imprisonment background factors such as: (i) whether or not one had a history of previous outpatient psychiatric treat- ment; (ii) whether or not one had previous inpatient psychiatric treatment; (iii) whether one did or did not have a history of drug misuse. Similarly there was no significant relationship between difficulty coping with impris- onment and various current factors such as: (i) whether or not this was the first period of custody. However, the longer the period currently in custody the greater the difficulties coping with imprisonment (p < 0.001). There was

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TABLE 2 Relationship Between GHQ and Beck Scales and Coping with Imprisonment

Scales Very well Minimal Moderate/ F p< difficulties severe

difficulties

Mean (SD) Mean (SD) Mean (SD) GHQ Total 5.4 (6.7) 11.0 (7.8) 17.7 (7.0) 39.9 0.0001 GHQ Subscale 1 1.3 (2.0) 2.6 (2.2) 4.8 (9.9) 4.3 0.05 GHQ Subscale 2 1.6 (2.2) 3.4 (2.6) 5.3 (1.8) 39.5 0.0001 GHQ Subscale 3 1.4 (1.7) 3.0 (2.3) 4.3 (2.2) 25.3 0.0001 GHQ Subscale 4 1.2 (2.0) 2.0 (2.4) 4.3 (2.5) 28.9 0.0001

Beck Total 3.3 (5.8) 6.7 (8.3) 7.7 (8.8) 0.65 n.s. Beck Subscale 1 2.0 (2.7) 2.5 (2.0) 3.1 (3.8) 0.28 n.s. Beck Subscale 2 1.2 (2.4) 3.7 (5.7) 4.3 (5.3) 0.91 n.s. Beck Subscale 3 0.3 (0.8) 0.6 (0.8) 0.9 (1.5) 0.50 n.s.

no difference in the length of time currently in custody and the number of friends in prison. Thus there is no indication that the longer this group spends in prison the greater the number of relationships they establish. There was no significant relationship between difficulty coping with impris- onment and scores on the Beck Suicidal Intent Scale. Thus among those who reported moderate or severe levels of difficulty coping with imprison- ment there was no indication of higher suicidal intent, as retrospectively assessed for at time of being placed on SSS, than among those who reported coping well or coping with tolerable difficulty.

Disadvantages of SSS Prisoners were asked an open question regarding what was in their opinion the main disadvantage of SSS. Verbatim responses were noted and later transcribed for analysis. The main categories of response were as follows:

Sensory Deprivation: A total of 84 (42%) prisoners mentioned topics that fell under this heading, the most common of which were statements such as:

• nothing to do, no books, no smoking • lack of reading material and no personal belongings • no light for cigs, no water to drink, not allowed pen in cell • in a cell with nothing, and nothing to do • light burning all night, solitude, not having anything to read • boredom, staring at four walls • no access to radio, no exercise • freezing cold, nothing to do • don’t get books to read or glasses to read with • was too cold, felt particularly freezing, as if hypothermia starting • being stuck in that wee room, don’t know what day it is • being locked in empty cell, no books, fags, complete boredom • no bed, couldn’t sleep, just a gown and single blanket • like lying in a fridge • can’t get warm, freezing and light on which prevents you sleeping • freezing, dark and no exercise • nothing in cell, nothing to do, boredom

This was by far the most common theme mentioned by prisoners and the things they felt deprived of most were warmth, reading material, cigarettes, adequate darkness to permit sleep, and general sensory stimulation.

Degradation: This was the second most common issue raised by a total of 58 (29%) prisoners and was reflected in comments such as:

• it’s the silly clothes you wear, everybody looking and laughing with you wearing these when you are slopping out

• you’re like an exhibit, clothes don’t fit, it’s disgusting, fleas on bedding, treat you like an animal

• just the way you’re treated, dirty filthy sheets, mattress dirty, filthy, couldn’t believe it, stripped naked, shorts and vest

• really humiliating, walk from one end of the hall to the other to slop out, everybody watching you

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• felt as if it was daft, putting on gown and shorts • not allowed to wear own underwear, feels like a child, drinks in paper

cups • only get spoon to eat from • usually other prisoners make a fool of you • embarrassed, dressed like a clown • bit degrading what you have to wear, no socks, shoes, couldn’t even get

my glasses • very degrading, no dignity • being stripped of your dignity • felt degraded, everyone can see you • felt humiliated, people came to look at you as if you were some form of

cabbage • not having own clothes, condition of cell deplorable, mattress was full of

grit, shorts and gown itches, smells terrible, couldn’t eat any food in cell • way you get fed, paper plates and cups • everybody stares at you all the time

The most common descriptors used by prisoners to describe how they felt having been placed on SSS was embarrassment, humiliation and degrada- tion. These feelings were particularly related to the clothing they had to wear and also to a lesser extent the standard of cell accommodation avail- able.

Negative Emotional Effects: The third most common issue raised by 40 (20%) of prisoners regarding disadvantages of location on SSS concerned the potential negative emotional impact of being placed on such a regime as illustrated by the following:

• I became more suicidal in the cell • lying down there and starting to crack up as going to my head as I didn’t

like being locked up • it’s just like being in the digger, being punished as if they didn’t care • I’m just lying there with nothing but my thoughts, it’s just a punishment • makes you want to kill yourself all over again • if on the edge, would drive you to suicide, reminiscent of the dark ages,

should be done away with • it’s a downfall, it’s about 5 times worse, makes you more depressed, it’s

like being put on punishment • sitting talking to yourself drives you nuts • if suicidal could put individual over the edge • made me feel worse • brain left to just sit and think, so bad thoughts escalate • locked up in isolation not mentally healthy • my freedom is even more restricted than other inmates • made me feel bad, locked in, they didn’t care about you, didn’t trust you • felt no-one wants to know you or listen to you • no freedom, doing my nut in, unnecessary, more likely to want to top

yourself if you were that way inclined, but I’m not

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The main sentiment expressed in such comments reflects prisoners’ beliefs that location on SSS had the potential to worsen their mental health by making them feel more depressed and more suicidal. Furthermore, location on such a regime was often seen as either a punishment or an indication that staff were disinterested and uncaring.

Social Isolation: This was the fourth most frequently mentioned topic and was reflected in the following statements by 33 (16.5%) prisoners.

• stuck in cell all day by myself, don’t mingle with folk, on own a risk, healthier if others there

• nobody to talk to, need to be with somebody, I hated it • don’t get enough people to come in and talk to you, to counsel you • the worst thing is being locked in on my own • it’s a long day, mentally very tough, never anybody in cell for 4 days • makes things worse being isolated • very lonely existence, no opportunity to talk to others • makes you feel more depressed not talking to someone • being alone for so long, never going to get out, only opened up once to

slop out, that’s you • the isolation is frightening • as if no-one cared, but prison officers were nice to me

These statements reflect the basic need for most individuals for some form of regular social interaction. Prisoners were not criticising a lack of medical, psychiatric/psychological intervention, but rather commenting on a more fundamental and basic need for contact with a fellow human being.

Other Disadvantages The only other disadvantages of SSS that were mentioned by barely a hand- ful of prisoners were issues related to:

Uncertainty:

• not aware of what’s going to happen to you • wondering what was going on

Dependency:

• feeling of total dependence on others for any requirements I may have

Confidentiality:

• don’t like it when doctor comes in, don’t get chance to speak to him in private, he is accompanied by two officers, and the door is always open

Not all prisoners listed disadvantages associated with SSS. Indeed a group of 21 (10.5%) prisoners were unable to list any disadvantages associated with this regime.

Benefits of SSS Prisoners were also asked, in an open-ended manner, what in their opinion was the main benefit of SSS. One-hundred-and-six prisoners (53%) did not

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mention any benefit associated with SSS. Of the remainder the main response categories were as follows:

Prevention: This was the most common benefit associated with SSS as mentioned by 43 (21.5%) prisoners in statements such as:

• it stopped me from doing myself in • got me out of doing something to myself, happy to be on SSS because of

fear of harming myself • something is being done, you are being recognised and do have the

medical officer in the morning to talk to • for the ones who are suicidal there is nothing in the cell to hang yourself

with • when I came in I did go on it as I couldn’t trust myself and I might have

damaged myself • being locked up 24 hours stopped me from harming myself and I had

someone (nurses) to talk to • stop you trying to kill yourself, screw watches you 24 hours a day • at least someone is monitoring you, able to speak to someone • appreciated the supervision • allows close observation of someone who is mentally unwell • wasn’t anything in the room which I could harm myself with and the offi-

cers have been good to me, helpful, understanding, trying to calm me down

• they (prison staff) look after you and make sure you don’t have anything in your peter

• I felt safer, didn’t have access to things to harm myself

From these statements it appears that for a significant proportion of prison- ers SSS successfully restricts access to means of self-injury, reduces prisoners’ concerns about self-injury and provides reassurance and support from staff.

Reflection: This was the second most frequently mentioned benefit of SSS, raised by 21 (10.5%) of prisoners in statements such as:

• gave you time to straighten out your mind • gives me time to get my head together, I get peace, time to think • helped me realise not to harm myself, to do anything stupid • helps you an awful lot in that you get peace and quiet and it helps you get

your head straight • thought it was good, peaceful, quiet • gave me time to think • it’s cleared my head once and for all, I can concentrate again on my

papers and television • it’s helping me giving me more time to think about things • calmed me down a bit, made me think a wee bit about myself.

For a minority of prisoners, location on SSS gives them opportunity to reflect on various aspects of their life and reconsider troublesome issues in a positive and constructive manner.

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Solitude: Twelve (6%) prisoners mentioned issues that fall under this head- ing, for example:

• sometimes you feel you need a bit of space for yourself and not going to see anybody

• it keeps me from meeting other people • prefer my own company and get panicky in hall • it does help, getting away from problems, being on your own • quite good, keeps you out of circulation, don’t need to share a cell • a wee bit of benefit to me as I can’t stand crowds, have a quick temper

and get paranoid easily

For such prisoners SSS is beneficial as a means of social avoidance, thereby reducing social anxiety and providing solitude.

Protection: This was the last discernible theme mentioned as a benefit of SSS by a small group of eight (4%) prisoners as illustrated in the following:

• don’t have to worry about somebody going to attack you • it’s harder for other prisoners to get to you than if you were on normal

protection • better physical safety, because of the crime I’m charged with, inmates

express their revulsion in a very physical way • SSS feels more relaxed than if I’m out with other prisoners, I’m nervous

outside the door, feel safe within the cell, the prisoners think I’m in for child molesting

For this small group of prisoners, SSS appears to be of benefit as a means of protection from other inmates.

Discussion

It has been proposed that ‘questions about the prison experience are far more likely to distinguish between prisoners at risk of suicide and those who may not be’ (Leibling 1992). The present study would tend to support this viewpoint whilst also acknowledging the relevance of other individual char- acteristics and pre-imprisonment background variables. For example, for the sample of 200 prisoners identified as at risk of suicide, prison was often a friendless environment where difficulty mixing with other prisoners was commonplace. However, many of the sample also had a history of previous outpatient treatment and previous suicidal behaviour.

Similarly, ability to cope with imprisonment was associated with a combi- nation of background or pre-imprisonment characteristics and environ- mental and situational prison-related factors. For example, as regards pre-imprisonment features those who reported greater difficulty coping with the current period of custody were more likely than those who were coping well to have a family history of psychological problems, alcohol related problems and previous suicidal behaviour. However a larger number of prison related features were associated with poor coping ability such as having few friends in prison, having difficulty mixing with other prisoners,

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actual or potential self-injurious behaviour during current period of impris- onment, past and present psychiatry/psychological treatment in prison. For the group of prisoners under study, difficulty coping with the current period of custody was not related to a history of outpatient or inpatient psychi- atric/psychological treatment in the community, history of drug problems or number of previous times in custody. Furthermore, those who had been in custody longer were more likely to have difficulty coping with imprison- ment but no more likely to have established friends in prison.

Coping abilities are multi-factorially determined by past experiences, acquired skills, levels of competence, emotional state, current demands and desired outcome. This is also true in the prison context. However, coping in a closed, crowded and potentially aggressive environment is determined largely by one’s ability to interact successfully, form alliances, establish alle- giances, develop social networks and most importantly, acquire acceptance. For many individuals in prison this is a daunting task which is unlikely to prove successful and may therefore increase feelings of isolation, rejection, despair and self-injury. This may be especially so for those with a history of psychological/psychiatric problems which impairs their social skills, increases their social anxiety or has a negative effect on their emotional state thereby increasing the possibility of suicidal behaviour among a group who have often already exhibited such a response to distress in the past. For such individuals, location on SSS would seem to provide an environment that might further add to their feeling of rejection and social isolation. However, it is noteworthy that only a minority (16.5%) of prisoners complained of social isolation as a disadvantage of being placed on SSS. This is not to suggest that social isolation is an insignificant issue. On the contrary, for social beings, lack of contact with others can be devastating. But it is worth- while remembering that amongst the prisoners under study many were loners (35%) or had significant difficulty mixing (12.5%). Furthermore, 10% saw the solitude or protection that SSS offered as a distinct advantage. It is these issues that may explain the negative aspect of social isolation not having been as readily complained of as one might have expected. Nevertheless, both the negative impact of social isolation and the accepted difficulties that many of the prisoners experience when interacting with others may be rectified by locating such prisoners in small group supportive environments outwith their cell during the day. This would alleviate the pressure that many of the sample felt they were under when having to cope with large numbers of prisoners while also limiting the negative effects of imposed seclusion.

The most common complaint regarding SSS was the issue of sensory deprivation, mentioned by 42% of prisoners, which is certainly unaccept- able, anti-therapeutic and likely to worsen any negative emotional state that a prisoner may be experiencing. The issue of sensory deprivation is however rectifiable, and would also be remedied to a large extent by having those prisoners who are classified as ‘at risk’ in some form of closely supervised association during the day with access to reading and writing material, exer- cise, interaction with others, TV etc. If prisoners ‘at risk’ were in supervised circulation during the day there would seem little need for them to

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continue to wear the standard vest and shorts that are issued when on SSS. It is wearing of such clothing that prisoners find most degrading and a major contributing factor as a source of ridicule. Addressing the three issues of sensory deprivation, social isolation and the degrading aspects of the SSS regime would most probably alleviate the potential negative emotional adverse effects that a significant proportion of prisoners referred to. However, if this were to be achieved it is important that the need for an appropriately secure environment which minimises the risk of self-injury, is not compromised.

In considering modifications to the SSS regime one must remember that its primary purpose is prevention and this is acknowledged by 21.5% of pris- oners. As such we again return to the balance of care dilemma whereby the Scottish Prison Service must take adequate steps to reduce the risk of suicide among certain sectors of its population while ensuring that such a regime is not overly restrictive, spartan, punitive and thereby counter-productive. The balance that has to be struck in order to address this care dilemma, while acknowledging the above reports of prisoners, would appear to be a regime that offered supported, supervised small-group activity of at-risk prisoners during the day, with prisoners spending as much time as is feasible outwith their cells and in normal clothing, coupled with relocation of at-risk prison- ers to ligature-proof cells at night or at time of lock-downs and return to appropriately protective clothing, if necessary, when not in circulation. Such a system already operates in certain prisons. It is right to review procedures and regimes, especially as regards the potential negative impact they might have. However, it is also important to put such problems in context in that it is recommended that SSS be used for as short a period as is possible, which on average is 1.87 days for those identified as at-risk at time of reception and 2.59 days for those identified at some other point in custody, with a range of 1–37 days (Power and Moodie 1997). For those retained on SSS improve- ments in their psychological wellbeing is a priority. The present study suggests that by altering various environmental aspects of the SSS regime the negative effects of sensory deprivation, degradation and social isolation might be minimised, while still ensuring that the necessary preventative features are maintained and prisoners are constructively assisted in coping with the difficulties that imprisonment imposes.1

Note

1 Acknowledgements: We are grateful to the Scottish Office Central Research unit for funding this research. We are also grateful for the assistance and co-operation of the Scottish Office and Prison Service staff. The views expressed in this paper are those of the authors and in no way reflect the views of the Scottish Office or the Scottish Prison Service.

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Date submitted: April 96 Date accepted: July 96

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