Peer support in prison health care: an investigation into the Listening Scheme in one adult male prison

[Executive Summary] Introduction: Prisoners are six times more likely to take their lives than an average person in the UK. Current prison suicide prevention policy in England and Wales reflects the importance of peer supporters and working with outside bodies such as the Samaritans. Under the Listening scheme, a peer support system developed by the prison service and the Samaritans, selected prisoners are trained to listen in confidence to fellow prisoners experiencing psychological and emotional distress which may lead to self harm or suicide. The scheme originated in HMP Swansea in 1991 and there are now over 1200 Listeners across the prison estate. Peer support is an increasingly significant aspect of health care provision as emphasis shifts from treatment to the promotion of health and well-being. The published evidence base for the role of Listeners in the mental well-being of offenders is limited to a few small empirical studies and reviews and evaluations that have looked at the prison service suicide strategy as a whole. Furthermore, the prison population has increased dramatically in recent years and responsibility for prison health care has now been transferred from the prison service to the NHS. The aim of this research study was to investigate prisoners' willingness to use peers for emotional and psychological support, to explore the impact upon providers and recipients and to investigate prisoners’ and health care professionals’ perceptions of its effectiveness in reducing distress. Methodology: A qualitative approach in one prison has been chosen for this research to complement earlier survey based research and to enable a more in-depth investigation of perceptions and understandings. Face-to-face interviews were conducted with: six Listeners; seven prisoners who had used the Listening scheme; seven prisoners who had not used the Listening scheme; two prison officers; six health care professionals and the Samaritan Branch Prison Support Officer. In addition to the interviews, two Listener training sessions and one Safer Custody Group meeting were observed in order to gain an understanding of the training provided by the Samaritans and the contribution Listeners make to the safer custody strategy within the prison. Findings: The local Samaritan branch enjoys an excellent relationship with the prison and the operation of the scheme is a joint project between branch volunteers and the Safer Custody Office. Whilst the number of Listeners in the prison fluctuates owing to the natural churn within the prison system, recruitment seems healthy and there are three intensive training courses every year. But the prison is perhaps particularly fortunate in having such a well-resourced and committed Samaritan branch. Levels of awareness of the scheme are high and there is a basic understanding of its aims amongst prisoners whether they use it or not. The extent of use is somewhat difficult to ascertain as official prison records of Listener call-outs do not include informal contacts and follow-ups and are therefore probably an underestimate. Prisoners who use the scheme spoke of anxiety, depression, frustration with the practicalities of life in custody and the isolation of being removed from family and friends. Health care professionals also referred to the relatively high proportion of individuals with diagnosable mental health problems within the prison system and Listeners reported that a significant number of their clients self harm. Prisoners who had not used the scheme usually felt able to deal with their own problems or had other sources of support, such as cell-mates and visits from family members. Although most research participants acknowledged that seeking help might be interpreted as a sign of weakness in a male prison, there seemed to be a far greater likelihood that prisoners would turn to their peers than to prison officers or indeed, health care professionals, who were generally seen as less understanding and less approachable. Staff workloads also meant they had limited time to spend with individual prisoners. Listeners enjoyed their roles and spoke primarily of wanting to support their fellow inmates, but also the opportunity to escape the confines of their cell and pass the time in prison more quickly. They also seemed to benefit in terms of personal development. However, there are other, less altruistic reasons why a prisoner might wish to volunteer in this way including a guarantee of a six month hold before being moved to another prison and an individual cell. On the negative side, the emotional responsibility of listening to distressed prisoners and maintaining confidentiality in some of the most difficult situations can weigh heavily, although those interviewed for this study felt they generally coped well. Although there is good support for the scheme at an institutional level, there was some evidence that the attitude of individual prison officers could vary suggesting that early reservations about the Listening role had not been entirely eradicated. This occasionally seemed to impact upon access to the scheme if officers failed to respond to requests for a Listener. However, it should be noted that as only two prison officers were interviewed, this perception comes principally from prisoners and Listeners. Health care professionals expressed respect for the work that Listeners do, but Mental Health In-reach support workers in particular felt they needed more supervision and training in basic mental health issues. A peer support scheme within a custodial setting inevitably faces certain challenges. It can be abused by both providers and users. This did not seem to be a significant problem within the prison, but a small number of Listeners are dismissed from the scheme every year for passing drugs or mobile phones around the prison and prisoners can be refused access to Listeners if they are considered to be wasting time or becoming too dependent. Demand for Listeners is heaviest in Health Care, the Segregation Unit and in the evenings after lock-down. During the day Listeners are free to move around the prison, but at night they must be escorted. The small number of officers on duty at this time can create delays in response to call-outs, but it is difficult to see how this can be avoided and prisoners seem not to have experienced too many problems in this respect. However, Listeners do tend to be concentrated in one houseblock rather than being evenly distributed around the prison. Confidentiality is central to the Samaritan and therefore Listening philosophy, but it rests on the group rather than the individual and the Listeners did not generally have any difficulties in adhering to it. However, In-reach support workers in the prison questioned the principle in cases of potential suicide. Far more problematic was the issue of vulnerable prisoners (VPs). Application for Listener training is open to all prisoners irrespective of their index offence, but there is a great deal of prejudice against VPs usually regarded as synonymous with sex offenders. Not all trainees are happy to be trained alongside, or to be called out to, VPs. The prison has adopted a policy of VP Listeners for vulnerable prisoners, but this is dependent upon there being a sufficient number to meet the relatively high demand and does not always cover those VPs who are in Health Care or Segregation. At the time the research was being conducted, the few VP Listeners were also being denied access to group support from the Samaritan volunteers following an incident during one such session. Overall, the Listening scheme is seen to benefit the prison in a number of ways. At one level it provides a safe space in which prisoners can vent their frustrations thereby diffusing situations which might increase the volatility of the atmosphere in the prison. At another level, it provides additional support to prisoners in emotional and psychological distress and relieves the pressure on prison and health professionals. Many research participants struggled to find ways in which it could be improved, but the following suggestions were made: re-integration of the VP Listeners into the main listening group for Saturday support sessions the option for prisoners to specify the type of Listener, for example a Muslim or a younger/older Listener if required some basic mental health training for all Listeners speedier escorts back to their cells for Listeners when a call has ended a more equal distribution of Listeners across all the houseblocks hand washes for all Listeners the provision of one-to-one supervision for Listeners the ability to “book” Listeners an age restriction so that only more mature prisoners could apply to become Listeners pamphlets detailing the way the scheme works which could be pushed under each cell door. Future Challenges: Arguably the main concern that arises from our findings is how to provide a consistent Listening service to vulnerable prisoners. There appear to be two main challenges in this area; firstly to provide sufficient resources within prison services and secondly to address the negative attitudes expressed towards this group both by some prisoners and prison staff. The current Samaritan confidentiality policy provides certainty for the Listener and prison service however some consideration should be given to integrating basic mental health awareness and knowledge into Samaritan training. Finally the Listeners are often in possession of important information and it would be beneficial to consider greater integration into the health care team but at the same time maintaining the confidentiality principle and avoiding “medicalising the service.” Future Research: The data in the current study suggests that the Listening scheme benefits both the Listeners and the prison service. It could be argued that it is fundamental to the prison suicide and self-harm policy. However to date there have been no studies that have attempted to measure the outcomes produced by the Listener service or tease out its contribution in contrast to other important variables such as the role of other prison support services. One of the main challenges facing NHS services of all different kinds is to ensure that money is spent on evidence-based services. To this end some form of cost benefit analysis of the Listening scheme would be beneficial. Volunteers for the Samaritans do not have to opt to work with the prison Listeners. In the prison where this study was conducted the scheme was well resourced. We suggest that this leads to two future avenues for possible research: firstly to investigate the types of volunteers who wish to work with Listeners and equally importantly those who do not and secondly to examine how the Listening scheme operates in prisons where Samaritan resources are stretched to support the service. Conclusions: From the perspective of virtually all those who participated in this research - the Safer Custody office, health care professionals, prisoners, Listeners and Samaritans - this is a Listening scheme that works well. The Samaritan volunteers were universally praised for their commitment and enthusiasm and there was evidence of a strong and positive relationship between them and the prison. Most prisoners who had used the scheme spoke highly of their experiences and greatly appreciated the support it provided. The Listeners themselves derived a great deal of satisfaction from their work and thought they also benefited in terms of personal development. A few tensions were highlighted between them and prison staff, but this did not appear to be a significant problem and their individual relationships with health care professionals seemed to be based on mutual respect and trust. However, by its very nature, the scheme does present certain challenges and these still have to be addressed even in the more successful examples. In this prison, these seem to centre on the integration of VPs into the Listening scheme and the need to extend the Samaritan’s obviously strong relationship with the prison authorities to Health Care and possibly other areas of support such as the Chaplaincy. A closer working relationship with In-reach services in particular might facilitate better support and training for the Listeners and a clearer understanding of the way the principle of confidentiality is interpreted in the prison. In terms of best practice, there is much to be learnt from the way the scheme operates in this prison. However, it seems unlikely that all prisons enjoy the advantages of such a well-resourced and motivated local Samaritan branch. This only serves to emphasise the importance of effective management and co-ordination in the implementation of any peer support programme

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