Playwork in prison as a mechanism to support family health and well-being

Context

Reductionist approaches to prison health have prevailed strongly over the past century, resulting in models and approaches that have privileged disease prevention at the expense of more holistic conceptualisations of health (De Viggiani, 2006). There are many reasons for this, including the disproportionate rates of ill health experienced by members of this population (Woodall, 2016). Much of this is ‘imported’ into the prison setting as a result of prison populations being drawn from communities where poverty, deprivation and inequality exist, but other aspects of health may be compromised as a result of the socio-environmental conditions within the prison (Irwin and Cressey, 1962). Prisoners’ families also face distinct challenges, although their needs are often overlooked (Schekter et al., 2017). Social, psychological and economic losses are often reported by families of prisoners (Murray, 2005; Schekter et al., 2017), and moreover, prisoners’ children are twice as likely as other children to experience mental health problems, are more likely to have higher emotional health needs and are more likely to go to prison themselves (Henshaw, 2014; Murray, 2005; Seymour, 1998). Exact figures on the number of children with a parent in prison are unknown, although it is somewhere in the region of 200,000 in England and Wales (Waldegrave and Woodall, 2016).

Given the health and social profile of people in prison and their families, many interventions to address this inequality have focused on ‘treatment’ and reacting to issues as they arise – this has meant that an explicit focus on salutogenesis in prison populations has been lacking (Woodall et al., 2014a). Nevertheless, evidence has shown that prisoners often require time outside of their cell and ‘fresh air’ in order to remain ‘healthy’ inside (Woodall, 2010). Family contact in prison is also an important aspect of prisoners’ and their families’ health (Dixey and Woodall, 2012; Woodall, 2010) and forms the main focus of this paper. Family contact can happen in several ways, but predominantly through letter writing, telephone conversations and through face-to-face contact through prison visitation processes (Mignon and Ransford, 2012). The latter is considered the ‘lynchpin’ that keeps the majority of family connections together (Codd, 2008), and evidence shows how visiting can promote prisoners’ mental health by reducing social isolation (Cochran and Mears, 2013). Prisoners who have regular visits from family have a reduced likelihood of post-release depression (Wolff and Draine, 2004) and are also more likely to have better post-release outcomes in relation to finding employment (Niven and Stewart, 2005). Maruna (2001) has also demonstrated that those who desist from criminal activities, rather than persist, after a prison sentence have good family connections and express strong generative themes in their narratives (i.e. a commitment to their children). It is, of course, recognised that in some instances maintaining family contact is not appropriate, especially if the prisoner’s offence relates to domestic violence (Mignon and Ransford, 2012).

The most common form of prison visit takes place in communal prison halls, and during these visits, prisoners and their families are able to spend anywhere from 30 minutes to 3 hours together (Hutton, 2016). Standard visits are monitored closely by prison staff and generally physical contact is restricted (prisoners can embrace their visitors at the beginning and end of the visit session (National Offender Management Service [NOMS], 2011) because of security concerns in relation to the exchange of contraband (Woodall, 2012b). While prisoners generally look forward to visits, they have also identified the stress of family visits, or their infrequency, as a major impact on their well-being (Department of Health, 2002). Emotional and physical distress is more likely to be found by mothers in prison who have limited or no contact with their children (Mignon and Ransford, 2012). Yet, the barriers surrounding visits for families – the financial costs and emotional challenges coupled with the way in which prison can make visitors feel unwelcome – make visiting difficult (Dixey and Woodall, 2012). Light and Campbell (2006) noted the challenges of prison visits and the difficulty for families connecting in a natural way:

Then there is the nature of the visit itself. This is usually conducted in less than relaxed circumstances. Restricted time, and the starkly contrasting circumstances of the inmate and the family, can result in conversations being artificial and stilted, with everyone keen to make the most of the visit and not to upset the other person. Consequently, issues and problems may go unresolved and even unmentioned. (p. 300)

In England, the provision of visits and the ways in which they operate vary considerably between prisons, with specific institutions having idiosyncratic features and approaches (e.g. whether visits provision is organised by prison staff, or voluntary and community sector providers) (Browne, 2005; Light and Campbell, 2006). There has, however, been a greater focus on the ways in which prison visits and family contact, especially with children, are maintained and offered. Regular family days, toddler days, drama activities and homework clubs are examples of this expansion in provision (Hutton, 2016; Kinsella and Woodall, 2016). These sessions often provide a more intimate space where the ‘quality’ of family interaction and well-being is often greater (Hutton, 2016).

Prison play visits are an example where prisoners, their partner and their children can interact. These types of visit use trained playworkers to facilitate interaction and to encourage family bonding through exploratory child-led play. Playwork uses the medium of play as a mechanism to address various physical, mental and emotional needs of children and allows children a sense of agency in a prison environment where the structure and procedure are usually enforced upon them (Wragg, 2016). Allowing agency in a structured prison environment where security must be of the highest concern is rare (Woodall et al., 2013a), but research suggests that allowing prisoners’ families to make agentic decisions where power is limited is important (Foster, 2016). While play visits are a relatively new addition to the suite of prison visit options (Wragg, 2016), there is a growing evidence base which reports their success in achieving several health and social outcomes for both prisoners and their children (Hart and Clutterbrook, 2008; Tamminen, 1999; Woodall et al., 2014b).

There is a growing amount of research that has focused on prison visiting and the role of prisoners’ families in supporting rehabilitation (Foster, 2016), but there is little doubt that this has been overshadowed by a greater focus on other parts of the prison experience. Despite their prominence in prison life and their potential to support family health and well-being, the spaces in which visits take place is one of the most ‘underresearched carceral spaces’ and one which, is argued, merits further investigation (Moran, 2013: 174). Much of the research undertaken in the field of prisoners’ families and prison visiting is relatively small scale, usually because of ethical and practical barriers preventing access to this group (Codd, 2008). This has led several commentators to assert that the voices of prisoners’ families have been unheard, resulting in families being regarded as the ‘forgotten victims’ (Light and Campbell, 2006).

This paper reports findings from research undertaken in one prison where play visits have been operationalised for several years. The play visits can be tailored for children of various ages, but in this case are particularly used for children aged between 2 and 12 years. Drawing on a social model on health and on the wider determinants of prisoner health, the paper demonstrates the impact of play visits on the constituents of the play session. The paper focuses mostly on the impact of play visits on the prisoners themselves and the family’s perception of the impact on children. The paper argues that a broader view of health, which encompasses issues such as how family ties are maintained and enhanced, is important for those working towards reducing health and social inequalities for both prisoners and their families.

Methodology

The focus of this study is on prisoners and prisoners’ families involved in a prison play visit scheme in one men’s prison in Northern England. The prison is a category B institution ¹ and holds approximately 1,100 men. All aspects of the research followed the Social Research Association’s ethical guidelines and received university ethical approval. The governor of the prison granted permission for the research to be undertaken on receipt of the ethical approval from Leeds Beckett University. Given that only one family at a time can access the play visit at any one time, the numbers of families currently engaging regularly with the scheme are relatively small.

The value of qualitative research approaches when exploring facets of prison experiences cannot be understated. Codd (2008), for instance, discusses the ‘vivid and detailed information’ that can be ascertained through such approaches with prisoners’ families (p. 19). In this study, qualitative approaches were used to elicit the ‘lived experience’ of prison visiting. In relation to ascertaining the views of prisoners’ families, it is often the case that prison visitors’ centres are used as a prime location to recruit and sample (Foster, 2016). However, previous studies have noted the difficulties that this poses, particularly that prison visitors often do not have the time or inclination to participate prior to or after the visit (Dixey and Woodall, 2012). To counter this, telephone interviews were undertaken with six female prison visitors who had been involved regularly in play visits in the prison over the past 3 months or more – these interviews were usually conducted in the evenings at the request of participants and lasted between 20 and 60 minutes. There are pragmatic advantages to telephone interviewing, but there is also evidence which shows that individuals feel that the anonymity afforded by telephone interviews allows them to disclose more detailed information and not feel ‘judged’ by what they discuss (Ward et al., 2015). One concern was ensuring that potential participants were able to give informed consent. Prior to the interview, it was explained that the researchers were independent of the prison and that refusing to participate would hold no disadvantage to them or their partner in prison. Issues of confidentiality, anonymity and the right to withdraw from the interview at any point were explained along with the aims of the research. Participants gave verbal permission for the interviews to be audio-recorded (the process of providing consent was also audio-recorded and stored securely as a record).

To explore the views of prisoners involved in the play visit scheme, five prisoners who had regularly participated in play visits over the past 3 months or more voluntarily participated in a focus group after information had been distributed to eligible prisoners within the institution. The focus group took place in a private room within the prison, and due to security issues, a member of prison staff was present but did not contribute to discussions. Prisoners participating in the discussions had no connection to the visitors interviewed. Researchers have to critically examine whether participants in a focus group actually share their true thoughts, feelings and beliefs in the discussion. Hollander (2004) describes the concepts of ‘problematic silences’ and ‘problematic speech’ during focus group discussions. She suggests that problematic silences occur when participants do not share their experiences or viewpoints within the group and instead withhold their own point of view and perspective. Carey (1995), for instance, claims that participants may be reticent to share personal information especially when the levels of trust are low in the group. This may be particularly pertinent in prison environments, where prisoners can be wary and concerned with the presentation they give of themselves. In contrast, problematic speech occurs when participants share opinions that do not represent their true beliefs. Problematic speech often arises when there are pressures to conform, thereby leading participants to adjust their contributions to match others or when participants feel an expectation to offer information that they think the researcher wants to hear (Hollander, 2004). Given these distinct challenges, focus group discussions have proved a useful method when discussing vitiation processes with prisoners (Dixey and Woodall, 2012).

Data were analysed thematically with an emphasis on identifying inductive themes and patterns. Time was allocated prior to the development of thematic categories to become fully immersed in the raw data. Data familiarisation is perhaps an obvious step in the analysis of qualitative data, yet this process was critical for forming a firm intellectual understanding of the overall data set. After a process of immersion, codes were applied to the transcripts. The process of coding manually involved writing notes on the text, highlighting and using post-it notes to identify salient data segments (Ritchie et al., 2003). From the list of tentative codes, initial themes were abstracted and categorised; this required a great deal of interpretative work, but eventually reduced the data into a more manageable set of discrete extracts. As researchers we were mindful of generating themes relating to both the prisoner perspective and the visitor perspective and also in developing cross-cutting thematic areas where commonality of issues arose in discussion (e.g. cross-cutting themes on the benefits of play for the child). Essentially, this was a process of re-focusing the analysis, considering how the codes may be combined and amalgamated to form overarching themes (Braun and Clarke, 2006).

Findings

This section presents the findings from the research. Where appropriate, direct anonymised quotations have been used to illustrate key themes or issues.

Discussion

There are some promising shifts in the way that public health advocates and health promoters are considering the health of people in prison. While prison health management has traditionally been typified by reactionary physical care underpinned by a biomedical philosophy, a more holistic recognition is emerging in relation to the wider determinants of prisoners’ health (Ramaswamy and Freudenberg, 2007). This includes a greater focus on the principles enshrined in the Ottawa Charter (World Health Organization [WHO], 1986) with emphasis given to the role of families in developing healthy prison policy and in creating supportive environments for health (Woodall et al., 2014a).

The role that prison visits play in addressing prisoners’ mental health is increasingly recognised (De Motte et al., 2012) – especially in providing a ‘buffer’ from the realities of contemporary prison life, such as overcrowding and violence. Other literature shows how maintaining contact through prison visits is beneficial for improved social connectedness on release and a greater likelihood of reduced re-offending (Bales and Mears, 2008). This research has shown the benefits of enhancing the standard prison visits experience through using play as a medium to foster greater bonding between prisoners and their children. One of the key effects of prison play visits was the sustained contact that prisoners had with their children; with the more relaxed and informal conditions being crucial to fostering parental bonds. Others have argued how visits, temporarily at least, re-create domestic family life (Holligan, 2016). The enhanced ‘quality’ of the visit and the closer interaction seemed critical, and indeed, other interventions that move away from standard visiting processes report similar findings (Hutton, 2016). Family breakdowns during periods of imprisonment are common and ensuring that this does not happen is beneficial for individuals, communities and wider society. Much research has shown how prison policies and procedures detract from families wishing to stay in contact. Brooks-Gordon and Bainham (2004), as an example, argue that security and invasive search procedures ‘weaken the receptiveness of prisons to visitors’ (p. 12).

It would be naïve, however, to homogenise prisoners and their families and suggest that visits, or indeed play visits, are a ‘silver bullet’ to reducing health and social inequalities faced by this group. Instead, play visits should form part of a menu of options that prisons could offer to support prisoner and family well-being during a period of incarceration. Children who have a parent in prison face distinct challenges, ‘particularly in terms of their emotional health and wellbeing’ (Seymour, 1998: 472); this study does show that some of this can be countered by policies and practices that allow children to have more meaningful time with their father in prison.

The notion of a health-promoting prison has been discussed for over 20 years now (Woodall, 2016), and yet the import role that family connections play in both supporting prisoners’ health and overall family well-being has been significantly overlooked. Applied to prison contexts, the settings approach recognises wider determinants of health and moreover privileges a holistic view of health. The role that regular prison visits has on prisoners’ health and their families’ health is not fully understood, although this study does show that prisoners feel able to have more meaningful interaction and better able to reconnect as a father – this is an important aspect of prisoners feeling ‘healthy’ inside prison (Woodall, 2010). There are, however, wider implications of more positive and ‘family-friendly’ prison visits experiences. Research has shown that positive prison visits can create a calmer atmosphere that can reduce demands on prison staff workload – poor visit interactions, on the other hand, can create more volatile situations that staff must manage after the visit has ended (Dixey and Woodall, 2012). This would require further investigation, but the potential to minimise staff workload and reduce stressors on prison staff would be welcomed given the high levels of sickness and ill health in this group (The Howard League for Penal Reform, 2014).

There are also alternative arguments to providing prison play visits that cannot be ignored. Although there are no data to suggest that prison play visits cause increased security threats, prison visits per se can be seen to be a threat to prison staff as they open up the possibility of contraband being exchanged (Dixey and Woodall, 2012). Further exploration of this may be needed.

Clearly, the study’s cross-sectional design throws up several limitations. Most notably, longitudinal tracking of the impact of the play visits is unknown, and moreover, whether family bonds are maintained and enhanced post-release from prison is an area where further exploration would be recommended. One of the major criticisms of adopting the settings approach is that it fosters insularity and fragmentation (Dooris, 2006). This criticism is particularly appropriate in the criminal justice context, where prisoners often feel that progress achieved in the prison in relation to health, confidence and self-esteem is often ‘lost’ when returning back to the community setting (Woodall et al., 2013b). In relation to this, using play as a medium to foster interaction should ideally continue after release and, where necessary, supported by trained professionals. That said, the likelihood of this, given the apparent lack of political will for play per se, seems inconceivable that specialist playworkers working with prisoners will become more prevalent or expand into ex-prisoners in the community (Wragg, 2016).

Conclusion

This study, albeit modest in nature, contributes to gaining a greater understanding of an underexplored facet of prison life. It identifies the critical role of prison play visits and demonstrates the positive implications of these for health and well-being. Visiting can cause emotional strain for all members of the family, and moreover, there is pressure because of the limited number of visits that prisoners can receive to make these experiences as positive as possible. The literature shows that attributes of a ‘bad’ visit include discussions about financial difficulties or other domestic information and where strict time constraints within the visit do not allow resolutions to be achieved (De Motte et al., 2012; Holligan, 2016). In contrast, the factors that create a ‘good’ visit experience is poorly reported in the literature (Moran, 2013), although indication from this study suggests that prison play visits can increase intimacy and increase perceived levels of family bonding.

Individuals and organisations working to support and improve the health of the prison population have often neglected the critical role that families can play in this process. While a more holistic view of the prison setting, acknowledging the structural and environmental impact that the environment has on health, has emerged in recent times, the role of the prison visit is frequently neglected (Woodall, 2012a). Considerably more needs to be done to equip, support and empower families to play their role in the rehabilitation of prisoners – a sentiment echoed by Maruna et al. (2004) and by The Centre for Social Justice (2009). Play visits offer the opportunity for families to play an active role in shaping a positive future for those serving prison sentences. That said, the danger of homogenising prisoners’ families must be avoided, and this paper does not advocate play visits for all families and children. Such an approach would be oversimplifying the complex dynamic that prisoners and their families face. What this research, and other research focusing on the play visit, has revealed is that for some families and children, play visits are an important part of sustaining health and well-being outcomes. To this extent, play visits should form part of a suite or menu of options for families to stay connected.

A better understanding of the mechanisms underpinning the play visit in prison is needed through further research investigation. For example, how frequent and how often should play visits occur in order to maximise positive effects? Which families benefit the most from play experiences in prison? The majority of research in this area (Tamminen, 1999; Woodall et al., 2014b), including this study, has focused on men in prison, but further work is required to see how and whether hegemonic masculinities enable or constrain play visits being successfully implemented. Finally, the transferability of playwork interventions to mothers in prison or young offenders is relatively unknown.

Play tends typically to be misunderstood or trivialised by the adult population (Wragg, 2016), and its role in supporting prisoner and family health and well-being requires further evaluation and examination if it is to be feasibly part of mainstream service provision in prison settings. Nonetheless, this study has shown the potential value in play visits in prison to support the wider determinants of prisoners and their family’s health.