1 00:00:00,150 --> 00:00:07,350 Welcome to the Oxford University Psychology Podcast series. My name is Daniel Maun and I have Professor Seina Faizal here with me this morning. 2 00:00:07,350 --> 00:00:08,340 Good morning, Siena. 3 00:00:08,340 --> 00:00:19,140 Good morning, Professor Sceneries and is an expert in forensic psychiatry in understanding about mental health in prisons and suicide risk in prisons. 4 00:00:19,140 --> 00:00:25,890 And that's quite a diverse research field. Could you tell us a bit about how you got into that? 5 00:00:25,890 --> 00:00:31,980 Yes, well, I think like many researchers, it's partly a matter of chance. 6 00:00:31,980 --> 00:00:38,880 I was training as a junior psychiatrist here in Oxford and invited to be the research 7 00:00:38,880 --> 00:00:44,310 work on a study of older prisoners and on the prisoners had been studied much before. 8 00:00:44,310 --> 00:00:53,950 And I was interested in mental health on the prisoners and interviewed over 200 older prisoners over a couple of years or so. 9 00:00:53,950 --> 00:00:55,710 And that really sparked an interest. 10 00:00:55,710 --> 00:01:05,470 And then I trained in prison for perjury and then ended up working as a consultant for the psychiatrist and now predominantly doing research, 11 00:01:05,470 --> 00:01:13,890 but also still work clinically in a prison as a as a psychiatrist, as a visiting psychiatrist in a local prison. 12 00:01:13,890 --> 00:01:19,860 Your research field is actually received some national interest from the media both last year and this year. 13 00:01:19,860 --> 00:01:24,810 Well, increasingly over the past few years, particularly around the area of suicide in prisons. 14 00:01:24,810 --> 00:01:33,210 Now, why is that the case? Well, I think it's I think it's noted as an international problem, particularly in high income countries. 15 00:01:33,210 --> 00:01:38,880 So there's always been a lot of media coverage around the world, particularly in the UK. 16 00:01:38,880 --> 00:01:50,550 And I think the UK has been partly, I think because of the Howard League for Reform and and other third sector organisations, 17 00:01:50,550 --> 00:01:57,120 has raised this as an important issue, as a litmus test really about health generally. 18 00:01:57,120 --> 00:02:02,880 Public health and public health should include prisoners. 19 00:02:02,880 --> 00:02:04,350 So I think that's part of it. 20 00:02:04,350 --> 00:02:11,430 The other reason why it's perceived as a national interest recently is because the numbers have gone up, the numbers of deaths in custody have got up. 21 00:02:11,430 --> 00:02:16,380 They went up 30 individuals more than the previous year. 22 00:02:16,380 --> 00:02:20,550 And also there's quite a large burden of self-harm in prisons. 23 00:02:20,550 --> 00:02:24,540 So there's a lot of interest, obviously, in deaths. 24 00:02:24,540 --> 00:02:29,790 But actually there's over 20000 incidents every year in prisons of self-harm. 25 00:02:29,790 --> 00:02:37,590 And that's been going up, particularly amongst men. There's there's a number of reasons, not only the international context, 26 00:02:37,590 --> 00:02:46,080 but a local context where the numbers have gone up and the self-harm rates are very high. 27 00:02:46,080 --> 00:02:54,090 And you've done some interesting work in the internationally and looking at mental health rates and suicide rates in prison. 28 00:02:54,090 --> 00:02:56,430 Tell us a bit about that. 29 00:02:56,430 --> 00:03:03,600 Yeah, well, one of the things we wanted to do is try and synthesise the evidence around the world about prison mental health. 30 00:03:03,600 --> 00:03:13,380 So, I mean, the the one of the best approaches to that is reviewing the evidence and in a transparent, quantitative way, 31 00:03:13,380 --> 00:03:26,440 trying to pull studies which can be pooled to some extent together to get a picture of what are the main mental disorders and what's their prevalence, 32 00:03:26,440 --> 00:03:31,980 what explains variation between different preferences that are reported around the world. 33 00:03:31,980 --> 00:03:41,040 So what have you found? Well, I think the the the most stark figure is that one in seven prisoners have a major treatable mental illness. 34 00:03:41,040 --> 00:03:47,520 By that would mean a major depression or psychotic illness, such as schizophrenia, bipolar disorder. 35 00:03:47,520 --> 00:03:51,150 So that's that that's helpful because it helps policymakers, 36 00:03:51,150 --> 00:04:00,600 people in public health to think about the burden of disease in mental illness, in person as treatable mental illness. 37 00:04:00,600 --> 00:04:09,900 Um, we've also done some work on substance abuse subsequently, which was very high rates, particularly amongst women going into prison. 38 00:04:09,900 --> 00:04:16,530 And that's focussed very much around drug and alcohol problems, obviously, particularly drug problems and women. 39 00:04:16,530 --> 00:04:22,920 You mentioned that number one in seven prisoners have a major treatable mental illness. 40 00:04:22,920 --> 00:04:32,040 And this is internationally and presumably there's going to be quite a variation in the quality of psychiatric management in prisons. 41 00:04:32,040 --> 00:04:38,250 That's right. Yes. And one of the big differences is, is who actually administers the health care? 42 00:04:38,250 --> 00:04:45,450 So there's been two different models. One is the equivalent of the national health system runs prison health care. 43 00:04:45,450 --> 00:04:51,090 The other model has been justice departments around the world employ their own health care systems. 44 00:04:51,090 --> 00:04:59,910 And there's been a gradual move towards the national health running prison systems and and the UK has been at the fore. 45 00:04:59,910 --> 00:05:05,640 In front of that today, the NHS now runs prison health care. 46 00:05:05,640 --> 00:05:09,660 It's been difficult to know to what extent that's actually improved things, 47 00:05:09,660 --> 00:05:17,340 but there is some evidence that particularly if it's aligned with good quality care. 48 00:05:17,340 --> 00:05:28,110 So it's not just a question of who runs it, but it needs to be backed by having good quality standards, accountability. 49 00:05:28,110 --> 00:05:30,510 The involvement of academic medicine is very helpful. 50 00:05:30,510 --> 00:05:36,990 So if that if that all comes into the mix, then it does seem to health to to help health outcomes. 51 00:05:36,990 --> 00:05:44,520 Right. And you've done some research not only into the mental health of people in prison, but the suicide risk of people in prison. 52 00:05:44,520 --> 00:05:50,850 You made some interesting observations about the fact that they aren't the 53 00:05:50,850 --> 00:05:54,690 suicide risk isn't necessarily linked to the general population suicide risk. 54 00:05:54,690 --> 00:05:57,300 What's that all about? Yes, that's right. 55 00:05:57,300 --> 00:06:07,950 So, I mean, one thing about that is that it seems to firmly research that we've done, the suicide risk is elevated compared to the general population. 56 00:06:07,950 --> 00:06:15,210 So even if you compare prisoners with people of the same age in the general population, 57 00:06:15,210 --> 00:06:20,100 you find it's elevated somewhere like between about five or six times. 58 00:06:20,100 --> 00:06:25,680 Compared to women, it's even higher than women. It goes up to 10 to 20 times competitor. 59 00:06:25,680 --> 00:06:33,540 So we have this quite large differential with the general population, excess risk population. 60 00:06:33,540 --> 00:06:38,410 And one of the things we did is we try to look at risk factors and we've done this in different ways. 61 00:06:38,410 --> 00:06:44,610 But was you saying one of the interesting findings of the first piece of work that we did on risk 62 00:06:44,610 --> 00:06:48,690 factors was that there are some risk factors that are different than the general population. 63 00:06:48,690 --> 00:06:56,160 In the general population, for instance, marriage is thought to be a protective factor, but it seems in prisoners it's a risk factor. 64 00:06:56,160 --> 00:07:03,920 And there was also an indication, but not so strong an indication employment was a risk factor in prisons. 65 00:07:03,920 --> 00:07:07,650 Of course, it's a protective factor in the general population. 66 00:07:07,650 --> 00:07:12,980 And one of the theories that we've had about this is that it's something to do with the number of loss events. 67 00:07:12,980 --> 00:07:19,840 So you have more to lose than prison time and actually be in your suicide risk, elevate your suicide risk. 68 00:07:19,840 --> 00:07:27,340 So people who come in married, who've got jobs, plus a lot of them have underlying mental disorders, 69 00:07:27,340 --> 00:07:32,070 who have all sorts of other psychosocial problems going on. I mean, put all that together. 70 00:07:32,070 --> 00:07:40,140 The accumulation of those risk factors, unfortunately, does lead to elevated suicide risk. 71 00:07:40,140 --> 00:07:49,860 Is there more that we could be doing in prisons to help manage this risk and help treat these these people with mental health problems? 72 00:07:49,860 --> 00:07:57,270 Well, I think there is one of the things that we've been trying to demonstrate is the 73 00:07:57,270 --> 00:08:03,840 importance of treatable mental illnesses and their contribution to suicide risk, 74 00:08:03,840 --> 00:08:06,480 not just suicide or self-harm risk as well. 75 00:08:06,480 --> 00:08:15,780 That will have a huge impact because of the I mean, the extent of the morbidity of self-harm is so large in prisons, 76 00:08:15,780 --> 00:08:21,330 the effects it must have on prison staff and also other prisoners. 77 00:08:21,330 --> 00:08:28,560 I mean, there's a bit of contagion. So when people self-harm, it may spread in prison wings. 78 00:08:28,560 --> 00:08:33,670 When you talk about self-harm. What's that look like? Is it sort of is it cutting on the arms or what is it? 79 00:08:33,670 --> 00:08:39,480 It is cutting on the arms mainly. And there is also some overdose of medication. 80 00:08:39,480 --> 00:08:45,050 People store their medication overdose and people use other methods as well. 81 00:08:45,050 --> 00:08:50,140 There are certain other ways as well, but it's often ligatures as well. 82 00:08:50,140 --> 00:08:55,260 The time things around necks in particular. 83 00:08:55,260 --> 00:08:59,940 But cutting is sort of, as you say, a prominent way of doing it. 84 00:08:59,940 --> 00:09:04,530 So what else can people do? So I think it serves not just to treat the treatment of mental illness. 85 00:09:04,530 --> 00:09:10,380 What we have also shown is that it's often people have multiple mental disorders. 86 00:09:10,380 --> 00:09:14,940 So it's someone may have a depressive illness and those who have alcohol problems as well. 87 00:09:14,940 --> 00:09:19,530 Well, they may have some other problem on top of that. 88 00:09:19,530 --> 00:09:25,380 And we've shown it in women prisoners in particular. 89 00:09:25,380 --> 00:09:28,020 It also comes from trauma. 90 00:09:28,020 --> 00:09:40,320 Many of these women have had bereavements in their immediate family, but also very traumatic experiences growing up, being in care, being abused. 91 00:09:40,320 --> 00:09:50,220 So you put all that together. You create quite complex psycho psychological needs and probably requires complex solutions. 92 00:09:50,220 --> 00:09:55,320 But it's not just a question of primary care and medication. 93 00:09:55,320 --> 00:10:00,330 It's more than that. So that's one of the things and the other thing. 94 00:10:00,330 --> 00:10:03,670 Is is is probably something to do with the environment as well, 95 00:10:03,670 --> 00:10:11,060 and that we know a little bit that there are things like if you increase meaningful daytime activity, 96 00:10:11,060 --> 00:10:21,090 if you increase or improve relationships between prison officers and prisoners, they may also have a more difficult study. 97 00:10:21,090 --> 00:10:25,860 But there's definitely something about the environment and good relationships. 98 00:10:25,860 --> 00:10:34,050 And people talk about healthy prisons. And I part of it that that whole way of thinking is, 99 00:10:34,050 --> 00:10:44,350 is it's it's the prisoners live in very sexual contexts and want us to be aware of the wider context. 100 00:10:44,350 --> 00:10:53,910 So one of the things that we we've argued when we studied self-harm is it's if you know, an individual self harms, in a way, you have to be aware. 101 00:10:53,910 --> 00:11:00,760 You have to think about the people that we are vulnerable because of the contagious effect, the possible contagious effects of it, 102 00:11:00,760 --> 00:11:10,140 and maybe things you can do to to mitigate the risk in other prisoners who may be considering it but haven't actually self-harm. 103 00:11:10,140 --> 00:11:14,700 What about psychiatrists who are working in prisons? They're called in reach services. 104 00:11:14,700 --> 00:11:21,210 That's right, isn't it? Yes. These psychiatrists, who how do they actually manage this suicide risk? 105 00:11:21,210 --> 00:11:24,900 What do they do in the prisons? What does their candidate like? 106 00:11:24,900 --> 00:11:31,760 Well, I think there isn't there's a moral question, I think partly because prisons are very different. 107 00:11:31,760 --> 00:11:38,820 So some prisons have a lot of prisoners who are not sentenced. 108 00:11:38,820 --> 00:11:46,310 And so it's much more chaotic and and there is much more difficult to do anything because people are doing for sure. 109 00:11:46,310 --> 00:11:53,070 You have to move. They're going back and forth to court. So how are you supposed to actually intervene effectively? 110 00:11:53,070 --> 00:12:00,020 It's a real big challenge. The real challenge of the the psychiatrist do. 111 00:12:00,020 --> 00:12:09,600 Well, I mean, I think it's good, good, good practise following, you know, evidence based treatment to to treat mental illnesses. 112 00:12:09,600 --> 00:12:18,270 There is there are there are protocols in prison societies, management protocols, which are mainly administered by prison officers. 113 00:12:18,270 --> 00:12:27,690 And I think that's right, because most of the care is actually the psychosocial campus and this is given out by prison officers. 114 00:12:27,690 --> 00:12:32,820 I mean, they're there all the time. They make this sort of close relationships with prisoners. 115 00:12:32,820 --> 00:12:37,200 The health care staff just can't because they're not there to that extent. 116 00:12:37,200 --> 00:12:45,240 So there is also in that context, the work of psychiatrists liaising with different other people in prison, 117 00:12:45,240 --> 00:12:55,200 particularly primary care, but also prison officers to some extent. And I think just sort of helping helping the prison develop its policies, 118 00:12:55,200 --> 00:13:01,620 develop its guidelines and think about how to deal with high risk individuals. 119 00:13:01,620 --> 00:13:03,480 But actually, I think quite rightly so, 120 00:13:03,480 --> 00:13:13,290 a lot of the suicide risk management is run by by prison officers in conjunction with primary care, with the nursing staff. 121 00:13:13,290 --> 00:13:19,830 That's really interesting to hear. We are facing a lot of constraints in our country at the moment. 122 00:13:19,830 --> 00:13:31,110 And we've noticed that in psychiatry in general that are acute inpatient beds are reducing and that's putting a lot of pressure on the system. 123 00:13:31,110 --> 00:13:39,510 And and if you look back, you noticed there is a spezza decreasing if mental health, prison numbers are potentially increasing. 124 00:13:39,510 --> 00:13:46,820 And and if we look at the number of mental health problems in prison that you've suggested, is that a concern? 125 00:13:46,820 --> 00:13:50,790 Are we we moving people from one from one place to another? 126 00:13:50,790 --> 00:13:59,640 It is a concern. And there is some evidence to suggest that there is a phenomenon going on called trans institutionalisation. 127 00:13:59,640 --> 00:14:09,840 So the idea was from the 50s onwards that these large asylums would gradually closed down and you would get deinstitutionalisation. 128 00:14:09,840 --> 00:14:15,900 But actually, there is some evidence that it's been people have just shifted and unfortunately, we've shifted. 129 00:14:15,900 --> 00:14:20,250 Some of these people shift to the prisons. A lot of them shifted to becoming homeless. 130 00:14:20,250 --> 00:14:24,750 So, you know, the worst possible context in some to some ways, in some respects, 131 00:14:24,750 --> 00:14:28,320 for people to go into ending up in the criminal justice system and actually 132 00:14:28,320 --> 00:14:34,980 homeless when we know there are very high rates of mortality and of disease. 133 00:14:34,980 --> 00:14:39,750 Um, so there is that in countries like the U.S., 134 00:14:39,750 --> 00:14:45,330 that's a particular concern because the seven bed numbers have gone down by about 95 135 00:14:45,330 --> 00:14:56,010 percent and the three largest institutions hold psychiatric patients are prisons. 136 00:14:56,010 --> 00:15:00,370 And so the number of men in prison. 137 00:15:00,370 --> 00:15:11,790 In American prisons, it's more than the hospitals, so there is, I think in the U.K. and in in in Western Europe, 138 00:15:11,790 --> 00:15:18,420 that's less a little less stark because our prison numbers are much lower. 139 00:15:18,420 --> 00:15:24,750 But in some countries, it does seem to be quite a lot of transition utilisation going on. 140 00:15:24,750 --> 00:15:27,210 A recent piece of work in South America, actually, 141 00:15:27,210 --> 00:15:35,580 where they found a very close correlation between decreasing bed numbers, psychiatric bed numbers and increasing numbers. 142 00:15:35,580 --> 00:15:41,610 Of course, there are lots of secular trends that want us to take account of a difficult study. 143 00:15:41,610 --> 00:15:50,250 But but it's just the absolute numbers of people in prison is very high in some countries. 144 00:15:50,250 --> 00:15:55,770 And the absolute number of people mental lose as a consequence, very high. 145 00:15:55,770 --> 00:16:03,480 So really fascinating narrative actually, as a society advances a on that note, 146 00:16:03,480 --> 00:16:09,900 do you have any plans for future research in this area that that that looks 147 00:16:09,900 --> 00:16:15,990 at new ways or novel ways of managing people with mental health in prisons? 148 00:16:15,990 --> 00:16:25,800 Yes. So we're trying to develop ways of identifying high and medium risk groups. 149 00:16:25,800 --> 00:16:35,520 So a piece of work I'm involved in currently is funded by the Wellcome Trust is is really developing what we call clinical protection rules. 150 00:16:35,520 --> 00:16:45,270 So ways of prognostic rules and a way of trying to identify people that might benefit from more interventions, 151 00:16:45,270 --> 00:16:50,700 more management, closer management to their problems, particularly maybe prison. 152 00:16:50,700 --> 00:16:59,880 We've been very interested in the link between mental illness and reoffending and and and and what can be done to reduce 153 00:16:59,880 --> 00:17:08,490 the risk of reoffending and patients with with with mental health problems or prisoners with their health problems. 154 00:17:08,490 --> 00:17:13,290 Finding a system that's improving identification of these high risk individuals within prisons, 155 00:17:13,290 --> 00:17:21,120 absolutely within prisons are released from prisons and finding a way that scalable, simple, not very expensive. 156 00:17:21,120 --> 00:17:26,580 That would be the aim. And that's part of the work involved. 157 00:17:26,580 --> 00:17:30,270 Thank you, Professor CNR. It's been great speaking to you this morning. Thanks for your time. 158 00:17:30,270 --> 00:17:35,310 Thank you. And thank you for tuning in to the Oxford University Psychology Podcast series. 159 00:17:35,310 --> 00:17:38,403 Please do tune in again. Thank you.