Phil Eaglesham is a Health Improvement Programme Manager for NHS Health Scotland, a mental health nurse, an artist / musician and a childhood victim of murder.
For more on public health and justice see our Health and (In)justice issue from June 2014.
Nina Vaswani’s research on childhood trauma and the implications for young adults who offend has struck me as highly pertinent, thoughtful and person-centred. My own childhood was marred by the murder of my uncle, so its poignancy has also chimed. Her paper should serve to remind us of the depth of the challenge faced by professionals in the justice setting, but it also illuminates opportunities to build on the articulate, insightful personal disclosures by the prisoners she interviewed. I would like to echo points she has raised and offer further consideration that offending and victimisation has a public health story to tell.
Childhood for all is a cauldron of positive (protective) and negative (risk) experiences and the resilience and survival of children and young people, whatever the blend of these factors should never be underestimated. This balancing act is one I have performed with reasonable success in the 40 years since my own trauma. Nina explores behind a protective layer of stoicism and self-control to think at a deeper human level; underneath any dissociation, following on when prisoners choose to disregard, tune out or walk away. Such positive regard and perseverance is something we can all apply, including as victims in the justice system, despite how turbulent the current environment might seem at times. The sense of rebellion, behavioural risks and self-medication should not surprise us in the population she observed, but to maintain a sense of proportion we must also consider the generation concerned and the needs, risks and behaviours of their peers within communities.
Gender identity also appears to be critical in these participant snapshots. I feel this merits more consideration through the strengthening of parenting skills, the building of peer mentorship and by embracing family focused solutions. The personal testimonies she captures often focus on the family constellation, or perhaps the lack of it and as a victim of crime, I also know this story of fragmentation and eventual reconciliation.
Projection, displacement and denial as defence mechanisms are all illustrated in Nina’s paper, but it is important to always consider that these form part of a protective instinct for survival, before, during and after the prison experience. If anything, the environment and culture of confinement demands this response of both staff and prisoners. We must therefore guard against any sense of aversion, reticence or anxiety we might have in reaching those who have experienced trauma in childhood or adulthood, whatever their behaviours. We can initially do this by building on our current collective efforts to reduce suicide, to reduce drug related death and improve mental health. These more ‘acute’ needs are often a route map to tackling the more chronic and fundamental issues which drive the behaviours which Nina’s research hints at and to use of the interventions we know work to reduce these harms.
In public health and harm reduction for example we frequently see recent ‘acute’ trauma among injecting drug users; loss through drug related death and experiences of adult and childhood gender based violence which can exacerbate the ‘chronic’ childhood experiences which her participants recall. The high prevalence of trauma in this small scale study again should not surprise us and points to a similar bleakness in data on prisoner’s levels of drug and alcohol use, their BBV status and their overall poor mental wellbeing. We must however always remind ourselves that the deprivation within the communities of prisoner origin and the social determinants of poor health and inequality (such as housing needs and unemployment) are also what can drive this presenting picture. In contrast however, I also noted also that in the 2013 SPS prisoner survey, a majority voiced a desire for health behaviour change, a sense of hopefulness for the future and an openness to recovery.
Nina’s research brings many deficits to life, but I would urge us to also consider the maturity and insight which shines through in her study participant’s comments. The emotional holding environment and the relationships within prison, whether peer, custodial or therapeutic provide prisoners the breathing space for reflection, a lucid sense of proportion and importantly the privacy needed to recuperate, recover and reframe personal identity. The personal assets inherent in the snapshots provided, however complex the deficits are being described, still shine through. The ‘transformative’ aspect of confinement we all seek can be amplified by the efforts of prison, health and third sector staff, by peers, by mentors and facilitated through family support if we work together effectively. Recovery, rehabilitation and reintegration appear to me to be subtle code for the same redemptive human experience we all want, whichever our policy focus, professional approach or personal ethos.
While prisons can provide valuable structure, interventions and personal focus, the question of sustainability upon liberation and throughcare can loom large. I feel that the wider health improvement workforce, in alliance with community justice can provide some of the consistency and follow through required here. The challenge to us by engaging with the prison population is how to harmonise apparently separate strands of action to improve health and reduce offending effectively and ensure these also impact on communities to reduce inequality. Beyond the insights Nina gathered, some of which are profound and moving, we also together have to consider “what happens next?”, “which interventions work best?” and most importantly “what happens on liberation?”.
The key trick is not just to resource such support efficiently but to evaluate its effectiveness in improving health outcomes, reducing reoffending and narrowing the inequalities in a prison population which represents us all as a cross-section of our community. This is a big ask we must rise to by building a strong partnership between the NHS, prisons and third sector agencies and ensure that this is meaningful to communities and victims of crime. We should also focus our collective efforts on where we can potentially have the biggest impact by prioritising violent offenders, offenders who have experience of or perpetrate intimate partner violence, our most prolific offenders and ensure we capture and share our learning as we deliver this to build a community of good practice.
Nina provides a thought provoking, prisoner-centred piece of research which points to not only need, I feel but provides a gateway to potential alliances and solutions we all crave at the heart of our work. As professionals and in reflecting on my own experience as a childhood victim, we now have to work more effectively together by understanding not only the needs of our prisoners but the social determinants of their offending, applying the interventions which work most effectively and are impactful and considering at a deeper the personal meanings of confinement.
Some useful documents and web sites.
Better Health, Better Lives For Prisoners (ScotPHN, SPS, 2012)
Evaluating The Families Outside Family Support Worker Role from a Health Perspective (L. Brutus, Families Outside, ScotPHN 2011)
Act 2 Care Suicide Risk Management Strategy, (SPS 2005) (currently under review and new strategy due for publication in 2015)
The National Programme for Suicide Prevention.
NHS Education for Scotland, Psychological Interventions Training Programme
Healthier People, Safer Communities, Scottish Public Health Network, CJA Chief Officers Group, 2013 available online at:
Equally Well: The Report of the Ministerial Task Force on Health Inequalities
2013 Prisoner Survey (SPS): (a series of population specific reports are also available).