Covid recovery: learning from person-centred approaches

Annex 4: Case Study - Expert Review of Mental Health Services at HMYOI Polmont

1. Why was this case study selected as an interesting example of a Person-centred approach?

The Expert Review ^[17] offers an opportunity to explore the reality of what person-centred means within an environment which might, prima facie, present multiple barriers to seeking and providing such an approach. Although the setting is unique, many of the issues, in different manifestations, are present within the other case studies. In practice, person-centred approaches raise various ethical issues, such as the tensions between care and control; between autonomy and protection; between the individual and the group; and between the personal and the professional. All these challenges, and attempts to reconcile competing factors, are identified within the Expert Review and the Monitoring Reports.

The review was commissioned following an inspection by HM Inspectorate of Prisons for Scotland (HMIPS) at HMPYOI Polmont, including an inspection by Health Improvement Scotland (HIS) into the health and wellbeing of prisoners at that establishment. ^[39] Although the inspection was positive around the opportunities available to support young people with health and wellbeing issues, it noted the poor take up rates by prisoners of these services. The inspection also noted a high level of prisoners placed on Talk to Me (TTM)^[40], the Scottish Prison Service (SPS) risk management strategy for prisoners at risk of self-harm or suicide. The review sought to explore factors influencing the low levels of prisoner engagement with health and wellbeing services, and, in this, the experiences of staff, prisoners and their families were central.

The review identified factors which may increase mental health problems in custody and inhibit prisoners approaching and engaging with professionals. It was recognised that many people come into custody with pre-existing mental health issues and adverse childhood experiences (ACEs), factors which both make custody more likely and more challenging. The range of challenges faced by the young people provides an opportunity to test the holistic quality often attributed to person-centredness.

Pertinent features of person-centred approaches are touched on, and, while not defining the term, the review highlights some of the advantages of and barriers to professionals working in a framework of PCAs. Further, the experiences of prisoners, their families and staff can be drawn on to explore the concept of person-centred approaches beyond the individual.

The Expert Review is also interesting as it situates prisoners at HMPYOI Polmont within a policy context which recognises the complex and multiple issues experienced by prisoners at the establishment. Factors such as numbers of young people coming into custody is addressed under the presumption against short sentences in the Criminal Justice and Licensing (Scotland) Act 2010, although concern has been expressed that remand numbers remain high. ^[41]

Policies, national and organisational, around reducing risk of suicide and self-harm, such as Scotland's Suicide Prevention Action Plan: Every Life Matters ^[42] and the SPS Talk to Me strategies ^[45] are central to this review.

The liminal space between childhood and adulthood, occupied by young people in custody at Polmont, makes policies such as GIRFEC ^[39] (and now The Promise ^[1]) highly relevant. Similarly, the Whole System Approach to Youth Justice recognises the importance of understanding the holistic needs of the young person within their social context and seeks alternatives to prosecution and custody. ^[45]

2. What elements of this policy are of particular interest in relation to learning about person-centred approaches?

The issues presented in this case study, as related elsewhere in this document, are useful for testing various terms, which may be assumed to be synonymous but whose use requires analysis; these include concepts such as person-centred, person-led, and people-centred.

3. Does this case study relate to the period during which Covid restrictions were in place? If so, how?

While the Expert Review was conducted in 2019, and therefore predates the pandemic, monitoring reports cover the timeframe of lockdown, restrictions and emerging from that period.

This case study can be used to reflect on how the pandemic sped up the actioning of recommendations made by the Expert Review. Maintaining contact with people in the community was identified as an area where progress had been made, and staff were building relationships with the families of prisoners. ^[43] Virtual visits had been used during lockdown and restrictions, and it was hoped that this would continue. ^[44] The report also noted the positive development of in-cell phones being rolled out.^[17]

4. What were the enabling factors that supported a person-centred approach?

Staff/prisoner relationships were viewed as positive, and, in particular, health care staff as compassionate and caring; the quality of staff/prisoner relationships was recognised as being crucial to prisoners seeking support with emotional and mental health problems.

Staff acknowledged the importance of building therapeutic relationships with prisoners but that the time available to them was limited. Retention and recruitment of healthcare staff was recognised as a significant issue.

However, it should be noted that these relationships were often viewed as most positive when there appears to have been a trade off with other outcomes. In particular, the low numbers attending classes facilitated a high level of prisoner engagement. Similarly, while the need to minimise use of the Separation and Integration Unit (SRU) is understood, it was acknowledged that staff in the unit had excellent knowledge of the prisoners in their care and that relationships were positive ^{[49] [45]}. In both these examples, the staff/prisoner ratio was conducive to the relational aspect of person-centredness.

5. How does this case study help us to understand the strengths of person-centred approaches?

This example demonstrates the resilience of person-centred approaches in the face of the limitations identified below; the relational quality of person-centred approaches is an aspect which staff have agency over. Further, supporting relationships can help to identify and address some of the ethical issues raised below.

Various monitoring reports indicate that progress has been made in some areas identified in the review. Staff/prisoner relationships are described as being mainly positive and this has been a consistent feature of the reports ^{[46] [46] 18 [47]}, although it was reported that, at times, there should have been more interaction with prisoners during recreation ^[47]. While concern was raised about the numbers of prisoners in the SRU ^[18] it was acknowledged that efforts had been made to reduce this and to support prisoners to move back to the mainstream halls within an appropriate timescale. ^[47]

The value of relationships in reducing distress, and consequently risk of self-harm and suicide, was recognised. Positive relationships can be further sustained through supporting staff and the review recommended training, for all professionals, around trauma informed practice and, in particular, around the developmental stage of adolescence. For this to be put into practice, it was recommended that personal officers spend dedicated time with prisoners to build nurturing relationships and for health professionals to be freed up from other tasks in order to develop therapeutic interactions.

Better communication with the community, both professional and personal contacts of the young person, was recommended. This included providing families with information about the prison system and to encourage and facilitate the passing on of concerns about a prisoner's wellbeing to staff. Understanding the importance of informal support networks is a central feature of person-centred approaches, and there is evidence that this has been developing. ^[47]

All the above suggest that some aspects of person-centredness can be developed by practitioners in their day-to-day roles, notwithstanding the more structural constraints.

6. What does this case study suggest might be some of the limitations of a person-centred approach?

This case study finds layers of potential limitations to person-centredness, some are outside the control of the prisoner and staff, but others are indicative of ethical issues, tensions and conflicts.

It is necessary to acknowledge the seeming contradiction inherent in person-centredness in a setting where the person is not only involuntarily placed, but also where they are sent for reasons which are the very antithesis of such an approach. Consequently, there may be limitations on the extent to which a prisoner experiences person-centredness and recognises the term as meaningful.

The lack of choice extends further to the limits around how person-centred care is provided where a prisoner is assessed as being at risk of suicide or self-harm. Although not all such incidences require the prisoner to be placed in the safer cells, they were viewed as punitive and sterile by prisoners.

The limits of confidentiality, through information sharing, may also inhibit the experience of person-centredness. In this respect, the sharing of information between professionals, viewed as central to supporting a vulnerable prisoner and keeping them safe, could be a concern for a young person.

The review acknowledges the impact which a completed suicide has, not only on families, but also on staff. The understandable desire to keep a prisoner safe, may result in risk averse practices, including inappropriate use of the safer cells. The review recommended research be undertaken in relation to the impact on staff, prisoners and families of a death by suicide.

Additionally, the Talk to Me (TTM) procedures were regarded as impersonal tick box exercises. Other organisational features, from limited access to phones, often at times not conducive to the person being called, to the provision of ill-fitting clothes, were seen as impacting negatively on wellbeing.

Deeper layers identified in the review include some aspects of prison culture which make prisoners reluctant to seek help. Prisoners identified attitudinal barriers; some of the terms they use to describe how others may view them are emotive and stigmatising and could be experienced as depersonalising. Examples of this include a participant who stated they didn't seek support because "I felt like I was treated like a junkie, staff really judge you"^[17] (page 27), not accessing prisoner listeners (prisoners trained to provide emotional support) due to not wanting to be thought of as a "grass"^[17] (page 26). Another barrier within the prison culture is the perception that vulnerability can lead to bullying.

7. What is the key learning from this case study relating to person-centred approaches?

• This case study offers an opportunity to explore how different organisations and professions understand and practice person-centred approaches.
• The case study identifies some ethical challenges which require to be reconciled around person-centred approaches. In particular, the tensions between care and control, and between choice and compulsion which exist within the justice system, and within a prison setting in particular, can provide useful insight into the nuances and complexities of how person-centredness is experienced.
• Additionally, this case study demonstrates the resilience of person-centredness within the restraints of systems and frameworks which may present challenges to such an approach. Notwithstanding the limitations identified above, the review highlighted examples of positive staff/prisoner relationships and compassionate interventions which are crucial in person-centred approaches.

How to access background or source data

The data collected for this social research publication:

☐ are available in more detail through Scottish Neighbourhood Statistics

☒ may be made available on request, subject to consideration of legal and ethical factors. Please contact frances.warren@gov.scot for further information.

☐ cannot be made available by Scottish Government for further analysis as Scottish Government is not the data controller.