Prison population: mental health needs

Stakeholder and lived experience interviews

• Qualitative interviews were conducted with people within Scotland with lived experience of prison and mental health conditions, a range of executive and senior level professional stakeholders and operational stakeholders.
• Respondents with lived experience of prison and mental health conditions indicated they were unable to share mental health concerns with prison officers due to a pereceived lack of dignity and respect from them or that they lacked sufficient training to provide appropriate support.
• Executive and senior level stakeholders spoke of the need for a 'cultural shift' and that 'a big sea change' would need to happen for mental health to be more meaningfully supported within Scotland's prisons.
• Operational and executive and senior level stakeholders voiced a need for increased SPS and NHS resources and increased SPS training to support establishments to embrace trauma-informed practice.

To address the corporate element of the health needs assessment through representation of the views of a range of stakeholders and interested parties, six qualitative interviews were conducted with a range of executive and senior level stakeholders. Representatives from SPS with strategic, health, justice and governance remits were interviewed alongside representatives from the third sector, and bodies providing legislative and welfare oversight. A further nine interviews were conducted among NHS and SPS staff with care responsibilities and six interviews among people in Scotland with experience of prison and mental health conditions.

Operational interviews

• 2 consultants
• 2 prison officers
• 1 mental health care manager
• 4 mental health nurses

Lived experience

• 1 person on remand/ with serious mental illness
• 1 sentenced person/ aged 50+
• 3 community-based people
• 1 carer

In addition, a 'peer listening' exercise based on the topic guide was conducted with three individuals transferred from prison to the high secure State Hospital for treatment of their serious mental illness (SMI). Additional detail on the methodology is set out in Appendix E.

The interviews followed topic guides that reflected main aspects of the prison journey from reception to liberation and were tailored to each group being interviewed; stakeholders, individuals with lived experience and carers.

Perspectives of people in Scotland with experience of prison and mental health conditions and their carers

Reception, remand and 'jail life'

The consensus among lived experience respondents was that establishing suicidal intent was the primary focus of mental health enquiry at reception into prison. The extent to which mental health issues are explored at reception varied by establishment with some better than others. Reception was also the point at which prescription information should be conveyed to set up regular medication. The majority of respondents felt highly stressed and 'wracked with nerves' during reception and indicated it may be better to revisit some discussions a couple of days later. Those with multiple experiences of prison stated they were in 'crisis mode' and thinking ahead to 'jail life' issues such as 'who's in prison? What have I got to worry about? Where am I going to get put? Who's going to be there? Have I got enemies and have I got friends...getting my stuff. Does my family know I've been moved prison?' Respondents described how the responsibility was very much on the individual to engage and choose to share information with mental health services to gain any support.

Being housed within a remand hall presented a 'chaotic', 'noisy', and 'volatile' environment. One person described being on remand as having 'knocked me unwell'. Uncertainty in their living environment, with people constantly arriving and leaving along with no end in sight regarding criminal proceedings, led to a very 'draining' experience for people, with little available to provide purposeful activity and distraction. Contrastingly, for some respondents remand was seen as a stable environment, providing a break from the stresses of living with homelessness and substance use problems.

Relationships and interactions with officers and peers

A range of perspectives were offered about the role of prison officers and mental health. Almost all respondents spoke of officer interactions in general terms that influenced how they expected officers to support their mental health needs. Day-to-day officer interactions shaped the development of trust and the extent to which they felt comfortable sharing mental health needs that are seen as a vulnerability in prison. Although respondents spoke of officers who 'went above and beyond' providing or allowing 'informal' mental health support, there was mention of those who 'didn't give two monkeys'. Respondents indicated that they were unable to share mental health concerns with officers due to a general lack of "respect and dignity" they received from them, with a need for officers to recognise residents as "human beings" or that officers lacked training to provide appropriate support. Respondents viewed officers as gatekeepers who could deny access to mental health support and medication. If officers could not be seen to be supportive of day-to-day interactions, then they could not be trusted with the knowledge of mental health needs. Respondents did not feel listened to when they attempted to talk to officers^[3].

Respondents also had mixed opinions about sharing mental health needs with peers. Reasons for this included not trusting peers, concern about being labelled vulnerable and potentially exploited, alongside not wanting to burden others who have similar problems. Respondents had mixed perceptions of Listeners^[4], trained by the Samaritans. While some saw Listeners as a valuable resource, others viewed it as a service that could be abused and was something they would never engage with in part due to the Listener's position as a resident which meant they could affect no change in their circumstances.

Observation cells and the separation and reintegration unit

Reinforcing a reluctance to share mental health needs with officers was a perception that "their answer to everything is throw you in a suicide cell. So, then you end up even more stressed because they put you in a daft outfit and then they put you on 15-minute observations, even during the night". It was noted that where staff did talk to residents there was an undertone of risk aversion "if you do this [die by suicide] it's on us". The visibility of the observation cell next to the officer area, meaning the entire hall could be aware of who was being held in them and potentially marking someone as vulnerable, was an additional reason given by respondents to lie about mental health needs if questioned by officers. Placing someone in an observation cell has additional implications. For example, the whole hall may need locked up to facilitate 15-minute observations. Respondents described that this could lead to discord among peers, as could mental health driven disruptive behaviours that disturb the whole hall, for example constant banging on a door.

Only respondents with an SMI diagnosis had been housed within the SRU. They viewed this as a blessing and curse. From a positive perspective, staff within the SRU were seen as more highly trained with a better understanding of SMI than hall officers. Respondents described how their behaviour had not been interpreted as mental ill health until they reached the SRU, which led to a mental health referral. The main negative aspect of the SRU, which was also described in relation to observation cells, was that it was essentially an empty cell with nothing to distract respondents from how they were feeling^[5].

Mental health needs, support and coping strategies

Several respondents described how they made multiple disingenuous attempts to seek drugs from mental health teams to support substance use habits, or to sell for financial gain due to lack of external support. Others admitted damaging their cells to convince doctors they required medication. In some cases, this behaviour led to disrupted relationships with officers and mental health teams apparently denying access to mental health services when individuals were genuinely seeking support when they realised that their mental health was significantly deteriorating. Respondents described adopting coping strategies that helped them manage their own mental health including reading, listening to music, breathing techniques, and talking with specific members of the mental health team.

A minority of respondents were receiving mental health support prior to imprisonment. Overall, respondents described having positive relationships with mental health teams. However, while respondents felt that being offered antidepressant medication seemed to be the answer to every mental health need, they also voiced a desire for talking therapies and for mental health team staff to encourage greater engagement with available self-help resources, such as by demonstrating coping techniques like guided breathing. This sentiment was raised where mental health teams cared for large populations.

Individuals described that despite spending time in observation cells, including following attempted suicide, they had little contact with the mental health team. Family members described feeling frustrated that the opportunity of stabilising and addressing substance use problems or other drivers of mental ill health within prison was not being utilised. In their view, attempts generally fail as engagement is central to mental health treatment within establishments yet many are unable to do so. For example, a carer commented that their partner "was too unwell to know to engage". Family members also voiced concerns that the needs of those with SMI who avoid being placed in an observation cell or the SRU may be invisible to officers and therefore overlooked by mental health staff because they isolate in their own world. This left families feeling isolated and frustrated that missing the opportunity to address underlying needs, which time in prison can provide, would leave their loved ones repeatedly returning to prison.

Liberation

A majority of respondents had experienced liberation at least once with little, if anything, positive said about the process. This included people being liberated after long-term sentences and from prisons respondents considered to be generally 'good'. While liberation on parole was associated with greater throughcare planning regarding housing and benefit applications, little support for mental health and substance use problems was described except being told to see community teams, GP etc. Moreover, while appointments in the community were generally made for them prior to release by mental health teams, respondents described experiencing various issues that could prevent them from attending, for example illicit drug seeking. The lack of appropriate support after release, which contributed to disrupted transitions from custody to the community was viewed by respondents as a missed opportunity, particularly by family members. Respondents gave multiple examples of being recalled to custody or being remanded within a few days of being released. Several described how they were released from prison with no support and found themselves homeless.

Successful transitions were reported when people received support from community psychiatric nurses and third sector in-reach work. Respondents described how engagement with third sector organisations, fostered by interaction with peer support workers, supported them through those first few high-risk weeks and helped break the imprisonment cycle by, for example, securing accommodation and therefore avoiding homelessness and the chaotic lifestyle that can bring.

Executive and senior level stakeholders

Prison as a part of the wider justice system

A majority of respondents commented that it was difficult to reflect on mental health within the prison setting without considering it as an element of the wider justice system. Diversionary schemes, which direct individuals away from a custodial disposal due to their evidenced needs, were not seen as working efficiently.

Scottish Prison Service corporate aims

Almost all respondents recognised the impact of entering a closed institution upon mental health and wellbeing. They also noted the corporate aims of the Scottish Prison Service in relation to identifying and supporting those with mental health needs.

While SPS respondents acknowledged a focus on health within the prison service, with note of ongoing mental health strategy and policy development, they also mentioned the need for a more meaningful and joined up approach with greater strategic direction to overcome barriers. All respondents commented that improvements are being made, however further development was required with talk of the need for a 'cultural shift' and that 'a big sea change' was necessary for mental health to be more meaningfully supported within Scotland's prisons. Respondents commented that policy and practice needs to be more responsive to support the ever-changing needs of the prison population.

Almost all respondents discussed that underpinning this 'cultural shift' was a focus on establishments adopting a more trauma-informed approach. The key principles underlying the trauma-informed approach are: safety, trustworthiness, choice, collaboration, and empowerment with a view that adoption of a trauma-informed approach will support trauma survivors in a way that provides hope, empowerment, and support that is not re-traumatising (The Scottish Government 2021b). Embracing a trauma-informed approach would place a greater emphasis on recovery within the prison environment and, in particular, the life journey that leads an individual to prison; for some on multiple occasions. While respondents recognised that prisons cannot 'fix' everybody, their view was residents should leave establishments with better life opportunities than they arrived with. Respondents noted that a lessening of the culture of risk aversion had led to a more person-centred approach within establishments. However, there were concerns surrounding the levels of scrutiny establishments are subject to, particularly where adverse events occur, such as a death in custody, and how that colours local decision-making in relation to mental health needs.

To reframe how prison officers care for individuals, most respondents mentioned a requirement for appropriate training, support, and resources to address the mental health issues facing officers on a daily basis and the development of a more trauma-informed environment. Respondents indicated that the dynamic also requires change with officers engaging with residents rather than residents raising issues. Although respondents indicated that relationships with partner agencies, such as third sector services, should be strengthened, it was noted that prison walls are 'more porous' in relation to collaborative working. Half the respondents voiced that both SPS and the NHS did not have a culture or forum for sharing best practice or other knowledge exchange relating to service development.

Prison as an extension of the community

Most respondents voiced frustration that the prison environment is perceived as similar to the community when it comes to implementing recommendations or delivering health services. A failure to consider the legislative and risk management aspects associated with caring for an individual within establishments, and how that was reflected in day-to-day management was highlighted by respondents. A lack of recognition of how the physical environment and layout of prisons could impact upon the implementation of recommendations was also raised. Although most respondents expressed that there should be parity of access to services available in the community and within prisons, it was emphasised that they require to be delivered in a different way, for example by different staff groups or via virtual services. An executive stakeholder noted that community GP practices receive additional funds where they support patients from areas with high levels of multiple deprivation. Disparity in funding was noted as prisons do not receive those funds despite the demographic and complex needs of the prison population. Funding was incorporated into NHS Boards' general allocations when the responsibility for the provision of prisoner healthcare transferred to them in 2011-12. Respondents voiced that prisons are under pressure to do more to support mental health without training or appropriate resources.

The COVID-19 pandemic: learning points from the prison response

A minority of respondents voiced some concern that access to mental health resources diminished during the height of the COVID-19 pandemic, primarily due to prison and NHS staff being required to cover essential services such as medication delivery because of staff shortages. In addition, respondents noted that residents who were already separating themselves from prison life due to mental health needs were less visible to staff and could easily be overlooked.

Counterintuitively, half the respondents reported positive feedback from residents regarding being in small household bubbles with lock up at 5pm and loss of evening recreation to limit viral spread through interpersonal mixing. Respondents described people in prison and prison officers reporting feeling a sense of safety through a reduction in mixing with others, better prison officer and resident interaction and the provision of mobile phones to facilitate in-cell communication with loved ones in the evening. An individual with lived experience also indicated the days went faster with an earlier lock up. SPS listened to feedback and indicated that a central tenant of establishments opening up after lockdown was that household bubbles and the associated sense of safety are maintained with a greater focus on meaningful activity and what that actually means. Respondents highlighted that the opportunity for staff and residents to get to know each other better within household bubbles led to improved, and more trusting relationships. In turn, this could encourage residents to be more open about their needs with prison officers.

Shared values, SPS/NHS alignment and working relationship

Most respondents recognised that the NHS and SPS have different corporate aims and although they operate as partners their relationship could be stronger. Respondents noted that while there are difficulties for SPS in establishing consistency of approach across the nine NHS Boards that deliver services within prisons in Scotland, the NHS have similar challenges operating within prisons of different sizes leading to mental health teams operating differently. The need for change to better support mental health needs within the prison environment was raised by respondents and is recognised within both the NHS and SPS. In particular, SPS respondents indicated that both strategy and language to progress cultural change was being developed at higher levels. Respondents highlighted that the COVID-19 pandemic had demonstrated that health was core to what SPS deliver: 'If people don't feel well and feel safe and have got that emotional confidence that they can engage with people and with services, then we're not going to get very far'. Mention was also made by a respondent of how several prisons have established joint NHS/SPS partnership boards and were able to act on published recommendations more readily.

Although most executive/senior level and some operational stakeholders spoke of good NHS/SPS relationships, there was a view that SPS and NHS should be communicating and working together more cooperatively to better support people living in prison. The overall impression from respondents was that the NHS and SPS did not always fully appreciate the extent of support they can provide one another. This included, for example, during liberation, or how minor changes to one system can greatly impact another, such as delays in escorting residents to a clinic at the health centre can greatly affect how many people can be seen in a session.

Operational, executive and senior level stakeholders

Mental health needs of the prison population

Although there was little consistency reported by respondents in how mental health needs were detected by different establishments during the reception process and the days that followed, all methods involved various screening tools and members of both SPS and NHS staff. The one commonality respondents identified was the need for the individual coming into prison to engage with staff and choose to share how they feel or what they are thinking at a point when they were likely to be feeling scared, uncertain or vulnerable.

Most respondents indicated that obtaining information about previous health treatment within the community and current prescription medications on reception involves a somewhat patchwork approach, with pockets of information available from various sources in a range of formats. Respondents highlighted that computer systems and NHS Boards cannot always easily communicate with each other, posing significant issues of information sharing at entry and exit from custody.

There was uncertainty among most respondents about whether there had been an increase in the number of residents presenting with mental health needs or if their mental health needs were simply being more readily identified and referred to services. There was, however, a shared perception among respondents that those being referred to mental health services were presenting with more complex needs. Respondents indicated that underpinning this increase in the complexity of needs was the concept of trauma with residents either more comfortable with disclosing past trauma or staff more readily identifying trauma-related needs. Respondents discussed that mental health services were striving to make prison officers more trauma-informed and formally/informally providing training and support around how to keep people safe whilst treating them in a compassionate, empathic, trauma-informed way. Respondents reported instances where prison officers were endeavouring to understand and support residents without automatically placing them on 'Talk to Me'. While prison officers understood that for confidentiality reasons they were not privy to health information, they indicated that knowing a little more about residents would help them better understand behaviours and interact with individuals under their care. Respondents commented that prison officers wanted trained and supported to better relate to and manage those within their care.

A third of all stakeholders felt that services are collectively (SPS and NHS) failing people who have been to prison multiple times by not addressing past trauma and that they are simply 'putting [a] sticking plaster over it', and that 'it feels like often it's firefighting'. This failing was related to a need for greater resources and training within both SPS and NHS.

Resources and funding

Regarding resources, the overall picture from respondents was one of limitations relating to NHS staff shortages, the constraints of the physical environment within prisons and prison officer shortages, which affected service delivery and led to trained NHS staff underutilising their skills when having to cover non role specific tasks and delivery of medication. A clear view from respondents was that NHS staff were 'under resourced and overworked' and that while there was a focus on mental health teams, this view extended across primary care and substance use services. Within establishments with only one mental health nurse, comment was made by a respondent that their 'caseload must be horrific'. However, another respondent from a better resourced but small establishment noted that the 'luxury of being a small prison [is] we can spend more time with our patients'. These comments highlight the disparity across the prison estate in the number of residents cared for per WTE mental health nurse and the real-world impact that these differences make to resident care.

While an essential task, a majority of operational respondents noted that daily medication delivery takes a large amount of clinic time away from health care staff, with delivery highly dependent upon SPS regime. There was little discussion about how this could be managed better. However, among higher level stakeholders, there was mention of considering risk mitigations, such as supporting individuals to manage their own medication. In addition to freeing up more clinical time, this could give some residents greater control over their lives and potentially remove feelings associated with a lack of autonomy and helplessness to manage their own health needs. This view was reinforced in the comments from an individual with lived experience who described how it "feels good" to be trusted with their own medication. Respondents highlighted that individual establishments also operate different prescribing formularies with medications available within the community not always dispensed within prison, leading to some residents having to adjust long-established medication regimes.

NHS teams were creative in finding ways to adapt services to support the needs of their population within the available resources or address failures in recruitment and retention of staff. Operational respondents cited examples including making links with nursing courses and welcoming students on site. This served a dual purpose of raising the profile of nursing within the prison environment and providing extra support. Greater integration of substance use and mental health nursing teams helped provide a more wrap-around service to the exceptionally high numbers of residents with mental health and substance use issues. Advanced Nurse Practitioners have been recruited in some prisons to support GPs with prescribing services. One service reported adopting a more community-orientated approach with all mental health referrals triaged through the GP service.

Respondents commented that while NHS clinical psychology services have been developed at several establishments, not all prisons have access to these services. This disadvantages those in receipt of therapy who are transferred to prisons without these services. Despite limitations in staff and environmental resources, respondents noted that mental health teams are continually adapting and evolving to improve services, to better meet the needs of their populations and to implement published recommendations. There was some evidence from respondents of best practice sharing but also comment of little time to engage more widely as priorities lie within their own service.

More widely, there was a call from respondents for 'more trained staff, be it prison officers or NHS staff, we need to understand more about it [mental health needs] before we can do anything about it'. Respondents indicated that better mental health training for prison officers would reduce the number of 'inappropriate' referrals to mental health teams that are situationally driven and potentially transient rather than indicative of mental ill health (e.g. receipt of bad news). Appropriate training for officers would also inform the development of a more trauma-informed environment within prisons; and, along with the development of a directory of on-site and third sector service providers, support prison officers to signpost residents to services suitable to their needs.

Observation cells/separation and reintegration units

There were mixed views from prison officer respondents about how often observation cells were used. One stated that they were regularly used to ensure the safety of an individual as staff shortages prevented support being offered to those unable to cope with the prison regime within their usual cell. However, another prison officer noted observation cells being used only as a 'last resort' and was unable to recall anyone in the recent past being placed on observation due to their mental health.

An executive level stakeholder questioned the effectiveness of placing those who express any degree of distress within an observation cell, devoid of interaction and stimulation and dressed in an anti-suicide smock. The further impact upon a person's mental health and potential future willingness to share distress was also questioned. Seeing people being placed into observation cells may, in and of itself, act as a barrier to others disclosing mental health concerns among the wider population. Half of respondents described that there was no middle ground for those in mental distress between single bare cells and accommodation in large halls, with 'safer' cells not always the answer, although SPS are currently assessing observation cells and how they are used.

The perception among some executive level stakeholders was that SRUs were being increasingly utilised to house residents in extreme mental distress. Although it was acknowledged that there can be difficulty in distinguishing behaviour related to mental distress from violent and disruptive behaviour. Where a lack of stimulation, peace and quiet were required, then the SRU was noted to provide that environment in comparison to the main hall. However the use of SRUs and prison more generally as a place of safety was questioned by respondents, particularly for those in acute mental distress who require assessment for transfer to forensic hospital. Work with the State Hospital was however ongoing to better support all individuals within the SRU.

Most executive stakeholders voiced concern regarding access to forensic psychiatric beds. Respondents recognised that the SRU is an area where high levels of staff input could be offered. However, this could also lead to difficulties reintegrating residents back to the main hall leading to resistive behaviours. Respondents cited regular discussions surrounding what support a resident required to transition from the SRU to the prison hall and, if they could not be delivered within the current establishment, then exploring transfer to another prison. An executive level stakeholder highlighted recent changes in the management of those who would previously have been housed within the SRU at HMP YOI Cornton Vale as an example of best practice and collaborative teamwork. This involved collaborative work between SPS, NHS Forth Valley, and the MWC to reduce the time required to transfer women out the SRU to a more appropriate setting in which to support them.

Respondents described using observation cells/SRU for the management of residents displaying psychotic symptoms related to use of NPS due to the risk they presented to themselves and others. Respondents saw the use of NPS within Scotland's prisons as inextricably linked to mental health needs and the underlying reasons for seeking and using substances.

The needs of specific groups within the prison population

While recognising that there were multiple specific groups within the prison population (for example, armed forces veterans, older adults, people with neurodevelopmental disorders), executive stakeholders noted that it was about 'focusing on an individual and identifying what that person sees are their needs, rather than us [SPS/NHS] undertaking some sort of diagnosis or assessment. It's about that engagement'. However, there was recognition that in many cases interaction and management would be guided by NHS staff.

NHS stakeholders voiced that they may be able to provide initial assessments and offer advice in relation to specific issues (for example, cognitive decline or alcohol-related brain damage), but ideally specialist community services would link into the prison. Respondents indicated there was a need for specialist services such as old age or substance use psychiatry within establishments, and some establishments had received some limited support. However, respondents noted that funding was generally unavailable for specialist services. Both executive and operational respondents commented about the number of individuals with past trauma presenting with personality disorder being managed by prison officers.

Respondents warmly mentioned links with third sector services and their contribution was widely recognised. Third sector services provided primarily support and assistance for substance use problems during liberation with separate groups operating to meet the specific needs of women. Respondents noted that third sector services had no formal links with health and wellbeing teams and were commonly linked to the recovery café/hubs operating within most establishments.

A minority of executive respondents recognised that people on remand were subject to a range of stressors including impending court cases and distance from loved ones. The majority of respondents indicated that people on remand had equal access to mental health resources, although referral to psychological services, where available, could be restricted due to the short length of time people were expected to remain within the prison. Respondents mentioned self-help resources and material that signposted residents to the mental health team, in addition to the referral process which could be self-initiated, or through peers, or any staff member. That individuals on remand have equal access to prison resources except for work was highlighted by respondents, although there was some question as to the extent they can access other rehabilitative or purposeful activities. Two executive stakeholders commented that in one establishment occupational therapists worked specifically with the remand population to help them develop good habits around mental wellbeing and encouraged engagement with resources and opportunities.

Liberation

Most executive stakeholders remarked how much of a loss to SPS and residents the removal of Throughcare Support Officers had been. While third sector services provided much needed support, there was a sense that it was an SPS responsibility to ensure a safe community transition and that all officers should be trained as Throughcare Support Officers. In doing so, this could allow relationships built over time between residents and officers to be utilised, particularly for people serving longer sentences. While respondents recognised that there were some good practices around liberation, with work by SPS to establish what that should look like currently ongoing, there was a lot more that could be done. Executive respondents commented that not every resident required pre-liberation planning and neither was engagement with planning enforceable. Operational stakeholders indicated that NHS staff made links with mental health community teams where there was a need, set up appointments, shared information and provided a supply of some types of medication. There was, however, concern about the transition from custody to the community. Respondents recognised the first few weeks of liberation could be challenging and chaotic. One mental health team member indicated they were attempting to standardise the liberation process while another noted that 'the mental health and welfare [support] of our patients should cover people getting out'.

Half of executive stakeholders highlighted that liberation support appeared to fail for people on remand, who could often be liberated without warning. Individuals on remand could also leave prison late in the afternoon with no support and no plan in place. One executive stakeholder implied third sector services would not support those who had been on remand or individuals with more complex needs. Supporting those with the most complex needs through the liberation process was previously an SPS role, as staff knew the individual and their needs.

Summary

There was a drive from the top of SPS to operate a more trauma-informed environment in Scotland's prisons. The COVID-19 pandemic has highlighted that the health and wellbeing of individuals in prison is foundational to the underlying aims of the prison service. Operationally, prison officers and NHS teams perceived residents as presenting with more complex mental health needs as well as trauma, and were striving to support residents with limited resources. From a patient perspective, the onus remains very much on individuals to choose to engage and share information with mental health services to gain any support from services.

People with lived experience indicated that reception was a time of extreme stress and that beyond establishing acute needs (i.e. immediate suicidal intent), mental health needs should be explored more deeply a few days later. Being on remand was a draining experience for people, characterised by uncertainty although for some it provided respite from homelessness. Some prison officers were acknowledged as going above and beyond to support mental health needs. However, the resident-officer dynamic needed improvement more generally, and mental health teams were supportive where they were not operating under an excessive workload. Liberation was most successful where third sector and community services provided in-reach support ahead of someone being released and during the high risk first few weeks which could break the cycle of returning to prison, for example by securing housing.