This Guide is aimed at individual clinicians - nurses, doctors or healthcare officers in the prison health centre. It is not a guide for managers about service development, nor should its advice and suggestions be viewed as mandatory Prison Service policy. However, as we recognise that services are at different stages of development in different establishments, we have included, where appropriate, brief suggestions for how services for particular conditions might be further developed.
The Guide emphasises throughout the contribution that staff from disciplines other than health can and do make to the management of patients with mental disorders. The management advice for each condition includes information and advice for healthcare workers to give, with patient permission, to prison officers and other staff involved in the care of the prisoner. The purpose is to ensure that the management of the patient supports rather than undermines recovery, whether the patient is on the wings, in education or workshops. The related information sheets for other staff are also aimed at that goal. Of course, on occasion patients may withhold permission for information to be shared. However, many will agree if asked, to at least certain information being shared in order that they may receive the most appropriate treatment on ordinary location.
This multidisciplinary approach is in line with standard 6 of the National Service Framework for Mental Health, which requires that healthcare workers provide information and guidance for those who provide regular and substantial care for people with mental-health problems. In the prison context, 'those who provide regular and substantial care' will vary. This is reflected in the wording used in the Guide. In the Guide for primary-care workers in the community, we use the phrase 'Essential Information for the Patient and Family'. In this Guide, we have substituted the phrase 'Essential Information for the Patient and Primary Support Group'. The primary support group might include family members, residential staff, workshop supervisors, chaplains or others as appropriate. Informing and supporting those who care for the patient, whether family members or prison officers, has to be done with patient permission (except where there is a risk of serious harm to the patient or others).
The Guide emphasises throughout the contribution that can be made by self-help, voluntary and community agencies. These agencies can help augment and support healthcare treatment, addressing the practical and social problems that cause or exacerbate illness and which healthcare professionals may be untrained or too busy to deal with. Poor access to such forms of community support makes the life of both prisoners and primary healthcare staff much more difficult.
The Guide attempts, as much as is possible, to give advice about dealing with the huge comorbidity which is the norm in prisons. Clinicians need to be aware of comorbidity of all kinds - between behavioural disorders, mental disorders and substance misuse disorders. Dichotomous thinking has no place in prison healthcare, eg that an inmate is either ill or dependent on substances, or that an inmate is either genuinely mentally ill or personality-disordered. It is essential to think multi-axially - to be aware of physical, social and psychological dimensions and also to be aware of multimorbidity.
Although this book is aimed at the individual clinician, it is important to recognise the crucial importance of the broader institutional context within which healthcare takes place. Mental health, in particular, is affected by environmental factors such as access to exercise, fresh air, constructive activities, time out of cell and contact with family and friends outside the prison. It is important for healthcare staff to actively promote health, including mental health, at both the individual and establishment level. How this may be done is set out in the World Health Organization (Regional Office for Europe) Health in Prisons Project Consensus Statement on Mental Health Promotion in Prisons (www.hipp-europe.org). This highlights the following practical and effective ways of enhancing mental health and reducing mental ill-health:
- regular physical exercise
- access to the arts
- antibullying strategies
- cognitive-behavioural therapies
- spiritual reflection, eg religion, meditation or yoga
- skills acquisition
- utilising prisoners' resources, eg for peer support.
A Management Checklist of prison procedures which can promote mental health within the prison is contained in the Consensus Statement.