Prisoners on prisons: Experiences of peer-delivered suicide prevention work

Introduction

Prisoner participation in prison life has become more prominent in European political agendas (Brosens, 2019). Peer support work – undertaken by prisoners with prisoners – increasingly forms part of prison suicide prevention strategies in countries including the United Kingdom (Buck, 2020), the Republic of Ireland (Griffiths and Bailey, 2015), France (Auzoult and Abdellaoui, 2013), Canada (Hall and Gabor, 2004) and Australia (Hinde and White, 2019). Peer approaches can offer social support (Adair, 2005) and opportunities to acquire new skills and give back (Edgar et al., 2011). Consequently, peer supporters can begin to resist negative labelling and forge desired selves by ‘doing good’ (Perrin et al., 2018: 759), potentially supporting desistance and mental well-being (Nixon, 2020a; Einat, 2017). Yet, significant concerns surround the exploitation of imprisoned ‘volunteers’ providing emotional labour for free (Hinde and White, 2019). Peer support has been driven ambivalently: by criminalised people seeking responsive methods and by neoliberal concern with cost savings (Buck, 2020).

Research into peer-delivered (suicide prevention) initiatives principally draws on accounts from serving prisoners (Perrin and Blagden, 2014). Longitudinal research is required (Griffiths and Bailey, 2015) and no studies have retrospectively examined prison volunteering with former volunteers. Prisoner authorship can expose conditions, prompt debate on reform, raise consciousness and assist people to process their confinement (Nellis, 2002). Prisoner accounts may support structural change, for example, Wildeblood (1955) added momentum to campaigns to decriminalise homosexuality. Despite efforts to position prisoners as agents in prison scholarship (Crewe and Bennett, 2012), there is limited peer-reviewed literature (co-)authored by people with lived experience of punishment (Bosworth et al., 2005; Weaver and Weaver, 2013).

Addressing gaps both in prison peer support knowledge and prisoner-authored scholarship, this article examines the experiences of five former prisoners who volunteered as emotional peer supporters whilst imprisoned in England. Our innovative co-authorship approach reveals overlooked challenges of prison peer support, centring former prisoners’ suggestions for improvement. First, we explore the literature on prison suicide, self-harm and peer support. Next, we outline our participatory approach to gathering and analysing qualitative data. Our findings provide a case study illuminating peer support limitations in prison and post-release. We highlight (i) high levels of need volunteers can face, (ii) inadequate resources to meet prisoner needs and (iii) opportunities for policy makers and providers to work with peer supporters to improve policy and practice.

Prison suicide and peer support

Suicide is the act of intentionally taking one's own life (Mind, 2020), although confused and mixed intentions are seen in self-inflicted prisoner deaths (Walker and Towl, 2016). Prisoners who self-harm and/or have histories of suicidal ideation are at increased risk of suicide while incarcerated (Favril et al., 2020). Across jurisdictions, prisoner suicide rates exceed those amongst comparable groups in the general population (Zhong et al., 2021). In western Europe, suicide rates exceed 100 per 100 000 prisoners (Fazel et al., 2017), generating very significant harms and costs (Tomczak, 2018).

High rates of suicide and self-harm in prison are a concern internationally. In October 2021, the UN Special Rapporteur on extrajudicial, summary or arbitrary executions identified deaths in custody amongst his four priority areas, stating: ‘most deaths in custody are preventable’ ¹ . Prison suicide reduction has been designated a priority activity by the World Health Organisation (2007) and England and Wales’. Nevertheless, suicide prevention practices in prisons remain ‘tenuous’, requiring empirically underpinned models of training and intervention (Cramer et al., 2017).

Prison suicide prevention analyses cannot be separated from broader questions including how many people we imprison, who is sent to prison and how prisons are resourced and run (Aitken, 2022). In many countries, imprisonment rates have increased dramatically over recent decades (Wacquant, 2010). In our case study jurisdiction: England and Wales, amidst static or falling crime rates, the prison population has risen by 70% in 30 years, maintaining the (second) highest imprisonment rate in Western Europe (Prison Reform Trust, 2018). Justice Secretary Grayling's benchmarking ‘efficiencies’ from 2012 generated the largest staff reductions in prison service history, leaving fewer, less experienced staff managing more prisoners (Prison Reform Trust, 2018). The voluntary early redundancy scheme also reduced prison staff levels, constraining the capacity to foster relationships and escort prisoners to health appointments (Howard League, 2017). Staffing ‘efficiencies’ correlate with increased deaths. Between 2012 and 2016, prison suicide rates more than doubled. 2016 saw a record high of 122 prison suicides (MoJ, 2017), followed by consecutive record rates of self-harm in 2017, 2018 and 2019 (Tomczak and Bennett, 2020).

In March 2018, U.K. government proposals to address prisoners’ mental health increased grant funding to the Samaritans charity, for their ‘Listeners’ peer support scheme (Tomczak and Bennett, 2020). Samaritans train prisoners nationally to provide confidential emotional support to other prisoners, aiming to reduce distress which might lead to (thoughts of) self-harm and suicide (Samaritans, 2020b). Local Samaritans volunteers train serving prisoners in listening skills, confidentiality and the law concerning suicide, following which prisoner Listeners provide 24-h confidential support to fellow prisoners and are escorted to callouts by officers (Foster and Magee, 2011: 13). The Listener scheme is the foremost prison peer support scheme, with Listeners in 112 prisons across the United Kingdom and Ireland (Samaritans, 2020a).

There are also many other peer support providers. In England and Wales, the Prisons Inspectorate (2016) listed 29 examples of peer support including Listeners, mentors and advisors. Some prisons also organise prisoner volunteers themselves to support emotional well-being (Telfer et al., 2021). Overseas, the Irish Red Cross organises volunteer prisoner peer educators to enhance health (O'Sullivan et al., 2020) and initiatives in Canada and France have introduced peer-to-peer programmes to prevent prisoner suicide (Brosens, 2019). Prisoner volunteers can uniquely complement statutory services, given their ability to reach prisoners who may see talking to staff as violating the ‘inmate code’ (Perrin, 2022). Benefits of the Listener scheme include support for prisoners in distress and reduced pressure on prison and health professionals (Foster and Magee, 2011). Listeners have also reported job satisfaction, empowerment and personal growth (Dhaliwal and Harrower, 2009). The benefits of peer support schemes more generally include support for prisoner mental health and deepened pro-social bonds (O'Sullivan et al., 2020; Telfer et al., 2021), yet peer supporters in prison also face significant challenges.

Prisoners who adopt peer support roles can be viewed with suspicion by inmates and the work may be burdensome, resulting in diminished confidence or burnout (Jaffe, 2012; Perrin, 2022). Peer supporters work amidst very high levels of need and limited statutory service provision. In England and Wales, 70% of male prisoners have an underlying mental health need but only 10% receive mental health services (House of Commons Committee of Public Accounts, 2017). 46% of women prisoners have attempted suicide at some point, yet only 28% said it was easy to see a mental health worker (Prison Reform Trust, 2021). More than half of prisoners were negative about the quality of prison healthcare (Prison Reform Trust, 2021). Imprisonment itself can induce psychological disturbance (Liebling, 2007), particularly as jails are ‘plagued by drugs, violence, [and] appalling living conditions’ (HM Chief Inspector of Prisons, 2016: 7). Despite this context, the U.K. government ‘does not know how many people in prison have a mental illness, how much it is spending on mental health in prisons or whether it is achieving its objectives … [improving mental health in prison will therefore] require a step-change in effort and resources’ (National Audit Office, 2017: para 1–2).

Amidst these conditions, peer provision holds the potential for exploitation, particularly during austerity. Volunteers may be required to complete duties previously undertaken by paid employees (Nixon, 2020b; Verhoeven and Van Bochove, 2018). In HMP Elmley, for example, prisoner violence reduction volunteers filled ‘the gaps left by the inconsistent staff presence’ (HMIP, 2016: 13). In coercive detention, ‘volunteer’ power relations are also problematic. Every element of a prisoner's behaviour is assessed to inform decisions about entitlements. The Incentives and Earned Privileges (IEP) scheme in England and Wales determines significant matters such as whether prisoners can wear their own clothes, have a TV, have visits, or be released (as discretionary parole decisions apply to some sentences). Prisoners are acutely aware of this scrutiny, which influences choices, including whether to volunteer and/or speak openly about any problems with ‘volunteering’. Moreover, these discretionary processes are affected by structural discrimination, with, for example, IEP decisions about privileges perceived by ethnic minority individuals as unfairly applied (ZMT, 2021). Qualitative, (auto)ethnographic work has revealed the value of insider accounts of prison suicide and related health cultures (Nixon, 2022), yet the focus of studies has often been prison officers rather than imprisoned volunteers (Ricciardelli et al., 2020).

Research design and methods

Our study employed a rigorous qualitative design, guided by an interpretivist philosophy (Bachman and Schutt, 2014), to consider how peer support was meaningful to participants. Most research about marginalised people is done by those who are not marginalised (Brown and Strega, 2015), which can result in participants’ experiences of pain ‘being used, manipulated and repackaged’ often without their knowledge or full consent, leaving minimal impacts on the lives of criminalised people or structural conditions (Booth and Harriott, 2021: 199). To avoid these omissions, we included formerly imprisoned peer supporters as co-investigators, extending the rich history of prisoner inclusion in criminology. For example, the tradition of ‘convict criminology’ elevates lived experience perspectives in knowledge production to sharpen analytical foci (Earle, 2018). We purposely included male and female co-researchers to overcome the historic marginalisation of women in (co)producing academic knowledge (Earle, 2018).

Our research question initially came from a former prisoner co-author, who felt that little criminological literature represented the realities of prison life. She theorised that writing by people with prison experience could lead to new knowledge and suggested a study bringing former prisoners and academics together to explore prison peer support work. The academics suggested ‘participatory action research’ (PAR) methodology. Participatory approaches belong to a ‘transformative paradigm’ (Mertens, 2009) in which the agency of participants is emphasised, and researchers and communities work together for social transformation. The researcher's role is to share information in ways that empower, aiming to redress inequalities (Mertens, 2009: 319). PAR assumes that people impacted by a topic should be co-researchers (Valenzuela, 2016), blurring researcher/ participant distinctions to create a democratic inquiry (Marshall and Rossman, 2011: 23) so that practice can be improved (McCutcheon and Jung, 1990: 148). Such collaboration can be time-consuming, but also educational and worthwhile.

Co-authors were identified through the Prisoner Policy Network (PPN), hosted by the Prison Reform Trust. The PPN is a network of (ex-)prisoners and allies working to include prisoners’ experiences in national policy development. Following University ethical approval for our study, a PPN representative invited a purposive sample of people connected to the network to participate. The inclusion criterion was experience in prison suicide prevention work. People released on licence were excluded due to the Prison Service research moratorium amidst the pandemic (MoJ and HMPPS, 2020). Co-researchers therefore had the benefit of some years since imprisonment to reflect, but limited experience during the pandemic – when well-being in prisons has worsened (Hewson et al., 2020). Our team assembles eight authors: three with academic knowledge of ‘criminal justice’ and five with lived experience of imprisonment. We occupy diverse, fluid identities (see Figure 1). Whilst we reflected on diverse identity positions, our sample was too small to reflect on how intersecting differences (e.g., gender, ethnicity, age) impacted peer support or establish significant differences across groups (e.g., male/ female). These would be useful foci for future research.

OPEN IN VIEWER

Figure 1.

Authorship team.

We adopted Ledwith's (2016) ‘cycle model’, which provides a template for critically considering social issues in partnership and taking action. Steps included: (i) ‘Being’, that is, noticing the issue of prison suicide, (ii) ‘Problematising’; group discussions of what is happening in prisons and why, (iii) ‘Conscientisation’; considering the implications of this issue and what should be done about it – via focus groups and writings, (iv) ‘Action’; co-writing this article, (v) ‘Making sense’; discussing desired outcomes from publications to planning next steps together, (vi) Communication; translating our work to stakeholders including voluntary organisations, prisons, policy makers and prisoners.

Our methods included (i) focus groups, which can generate in-depth discussions and place multiple perspectives in dialogue, potentially providing collective power to marginalised people (Liamputtong, 2011) and (ii) collaborative autoethnography. Autoethnography is a written method in which people describe the personal experience (auto) to understand cultural experiences (ethno) and systematically analyse them (graphy) (Gant et al., 2019). Collaborative autoethnography involves sharing accounts of personal experiences to support deeper analysis. This can result in highly personalised accounts from (frequently unheard) groups and offer ‘novice’ researchers an opportunity to deepen learning and develop with others (Gant, 2022; Gant et al., 2019).

Our initial focus group in September 2020 was attended by all authors, via online videoconferencing. One co-author prompted the discussion, asking how former prisoner authors learned they could volunteer in suicide prevention and what motivated them. The ensuing 100-min discussion was ‘unstructured’, to centre those most impacted. With the informed consent of the group, the discussion was audio-recorded and transcribed verbatim. After this group, all authors were invited to write reflections so that one month later, we could discuss these together. The writing process was explained at the end of the initial group:

Academic researcher: In a previous project like this, I wrote a draft and sent it to other authors. One co-author wrote her own sections, another spoke to me over the phone and said, ‘this needs to go in’, or ‘I don't agree with this’. So, tell me how you are comfortable working. You might want to call or just write your ideas …. You might want to write a poem or do something visual; we’re open to suggestions …. We have another three (optional) group dates planned if you want to test ideas. We’re learning here too, so if you’ve got ideas, tell us. You’re our co-authors.

Most group members were more comfortable talking than writing, so the academic partners wrote up some spoken reflections and linked these to others’ written reflections and wider phenomena. For example, recollections of peers responding to extreme distress with little support were linked to notions of secondary and vicarious trauma. The group then discussed the need for prisons and charities to recognise and minimise this potential. Reflection methods were deliberately adaptable to facilitate the inclusion of diverse competencies (Watson and Fox, 2018). One co-author reflected:

Feeling comfortable and having a safe space is paramount to extrapolating peoples’ lived experiences and not enough researchers allow time for this. Lived experience participants are often just “used” as we know all too well. This is one of the main reasons I usually decline to take part in research. (Emphasis in original).

Given that recalling experiences of imprisonment can be traumatic, we urge other researchers to consider the adaptability of research design to individual needs.

Additionally, the academic researchers analysed data thematically (Braun and Clarke, 2021), which involved coding and theme development. Coding involved reading the focus group transcript and written submissions, highlighting material and adding comments; interpretation involved creating clusters from codes and interpreting meaning in relation to the research questions. For example, codes such as ‘risky environments; high expectations; lack of care’ were grouped into themes, for example, ‘riskiness of peer support’, which was interpreted in terms of psychological well-being. Written interpretations were emailed to co-authors, who wrote remarks or made verbal suggestions. Four hour-long online meetings took place between October 2020 and January 2021, to clarify themes as a group and acknowledge any distress. In this way, the data collection and analysis were collaborative and recognised needs (Chevalier and Buckles, 2013). From April 2021 to August 2022, the paper underwent peer review by two social science journals and both rejected it after requesting revisions. Authors collaboratively planned amendments via email and videoconferencing. The first journal wanted more engagement with critical suicidology theory (e.g., White, 2017). However, we did not fully implement suggestions as they reduced the prisoner-led focus and the revised work was rejected. A reviewer for the second journal made negative assertions about co-authors’ level of training and ability to contribute to knowledge production. After strengthening our defence of subjectivism and autoethnography, the article was rejected again. As such, we have learned first-hand that peer review forms part of the knowledge hierarchy (Jaffe, 2017), which can be dismissive of alternative knowledge from groups that are rarely visible as authors. Despite resistance, we remained committed to defending our innovative approach and sharing our valuable data.

The power imbalance between researchers and (former) prisoners can result in exploitation (Dupont, 2008). We minimised this risk by inviting open discussions about our different positions, ensuring informed choice about accredited authorship/anonymity, sharing knowledge about research philosophies, methods and publishing norms, and valuing the ‘deep wisdom’ that emerges from reflection on experiences (Booth and Harriott, 2021). We also ensured that the team comprised more former prisoners than professional researchers and ensured that formerly imprisoned co-researchers were paid. Despite concerns that payment can induce participation and limit abilities to make uncoerced decisions, research participation decisions are based on multiple factors and incentives to communicate the worth and status of all persons (Hanson et al., 2012).

Decisions about anonymity were informed by the ‘hands-off our stories’ principles (Costa et al., 2012), which invite consideration of the risks of self-disclosure, given that experiences may be appropriated for organisational interests:

Participation is voluntary. You can always say no.

Findings

Although peer support can complement statutory services (Perrin et al., 2018), former prisoner reflections were dominated by the mental health crisis in prisons and the high levels of distress and self-harm that volunteers faced as a norm, with little structural or personal support. Sub-themes included (i) the riskiness of peer support; (ii) inconsistencies in training and working conditions; and (iii) the value of peer support. We explore these sub-themes, then propose co-created recommendations for safer service provision.

Recommendations

We have offered a new perspective on prison peer supporters: as crucial, often life-saving actors working in extraordinarily difficult and often unreasonable conditions, who have unique insight into the prison mental health crisis and who require organisational support. Reflecting our focus on lived experience, this section draws on former prisoner strategies for service development.

Our first recommendation is that safe opportunities for suicidal and distressed prisoners to be listened to should not sacrifice peer supporters’ well-being. Policymakers and voluntary organisations must recognise that volunteering whilst imprisoned is significantly different from community volunteering and seek to learn from people with lived experiences to shape services. Imprisoned volunteers are often bullied and/or exploited. They cannot seek comfort from loved ones or go for a walk after a difficult ‘shift’ as their ‘home’ and ‘work’ spaces are fused, and they can struggle to step back from their role when burdened by prisoner distress (Jaffe, 2012). At minimum, prisoner volunteers require respect and understanding from staff, safe working conditions and supervisory support.

Our second recommendation is for policymakers and providers to acknowledge and work to reduce the potential for secondary and vicarious trauma within peer support. Comprehensive volunteer training could introduce these concepts so that prisoners can make informed decisions about taking part. This is especially important given the prevalence of trauma amongst prisoners (Facer-Irwin et al., 2022). We also advocate that volunteers and prison officers be trained in trauma-informed principles (e.g., Bradley, 2017; Levenson, 2020), including how to respond sensitively to volunteers witnessing self-inflicted harm and death. Supervision meetings (not attended by officers) could facilitate debriefing and improve therapeutic interactions (Powers, 2017), safeguarding volunteers and recipients. Ideally, supervisors should understand the complexities of prison: signposts to helplines are only useful if volunteers can access phones and spaces for confidential discussions. Finally, as the primary predictor of secondary trauma is hours-per-week spent working with traumatised people, (Bober and Regehr, 2006) all volunteers should have a line manager who ensures safe working hours.

Our third recommendation is for voluntary organisations to regularly review volunteer experiences and mobilise this knowledge to stimulate changes in and beyond prisons. We have shared findings with one voluntary organisation and will share findings with more stakeholders. However, there is an opportunity for all peer support providers to develop forums to learn from lived experience and strategically plan and act. (Former) prisoners can offer valuable local knowledge (Fals Borda, 1988) and viable solutions (Peralta, 2017), which may be overlooked by others. Collaborations with (former) prisoners could develop services fit for purpose in their context. Peer supporters and providers could seek to influence qualitative changes, such as all volunteers having safe, clean spaces to work in; confidential supervision; and places to wash and receive support following incidents.

More broadly, peer providers could couple service delivery with ‘upstream’ pressure for structural reforms (Quinn and Tomczak, 2021). Voluntary organisations are well placed to broker systemic change (Tomczak and Buck, 2019), for example, prison peer supporters could catalog callout types with their employing organisation (e.g., self-harm/severe mental health episode), who could feed these insights into multi-agency planning/commissioning forums locally and nationally. Regular meetings between providers and volunteers (e.g., quarterly safeguarding reviews) could add (anonymised) context and facilitate coproduced action plans. Peer support providers could then feed levels of need to those monitoring deaths in prison such as (in England) the Independent Advisory Panel on Deaths in Custody ⁴ and the parliamentary Justice Committee, or (globally) Penal Reform International ⁵ , influencing policy on an (inter)national scale.

Critiques of coproduction argue that participants have little power to challenge or ‘change policy, neoliberal economic structures or austerity drives’, however, involving national social movements and policymakers ‘may support a wider force for change, illuminating different possible paths for the development of public services’ (Farr, 2018: 640). Anonymised records of (unmet) needs could align with campaigns to raise awareness of the scale of the prison mental health crisis and the unsuitability of prison as a ‘place of safety’ (Tomczak, 2022a), enabling voluntary sector actors to advocate for community alternatives to imprisonment and more comprehensive mental health provision within and outside prisons.

Conclusion

Deteriorating prison safety poses a major moral, social, economic and public health threat. The consequences of unsafe prisons are absorbed by societies. Of the 78,000 prisoners in England and Wales, fewer than 100 will never be released (Prison Reform Trust, 2021). Rising prison populations, staff reductions and significant increases in suicide and self-harm indicate that prisons are now less safe than at any point in recorded history. Using peer supporters as a major part of the response to this crisis (Gauke, 2018), problematically relies on imprisoned volunteers working in dangerous and distressing situations with minimal support.

The data from this exploratory study reveal the human impacts of such policies. Whilst most studies of prison peer support engage serving prisoners, highlighting the potential to support desistance and improve relationships with prison staff (Einat, 2017; Perrin et al., 2018), we highlight that peer supporters can experience major problems. Our innovative, participatory, retrospective design created space for former volunteers to reflect on the unique risks of peer support that can sometimes be overlooked or subsumed in more appreciative accounts, including fraught relationships, high expectations, limited support, and destabilising pressures. The analysis illustrated inconsistencies in training and working conditions, which can leave people ill-equipped for the levels of distress they encounter. Prisoners were often called to people experiencing acute mental health crises, who require professional healthcare. This brought awareness of the risks of secondary and vicarious trauma and generated optimism that organisations could better meet volunteer needs whilst steering health and justice policymakers toward more comprehensive mental health provision and diversion into healthcare. We reflected on the need for voluntary providers to highlight gaps in provision and avoid concealing problematic carceral practices and structural inequalities through sticking plaster solutions (Carlton and Scraton 2017).

We ended by discussing the value of peer support in prisons, given its unique ability to offer isolated and traumatised people someone to talk to and alleviate distress. Our solutions cultivated commitment to the therapeutic and safeguarding features of peer support alongside the belief that much more comprehensive mental health provision is required in (and in many cases instead of) prisons. Peer supporters are ideally placed to illustrate the unacceptable scale of the prison mental health crisis, enabling providers to advocate for alternatives to imprisonment, more suitable and comprehensive mental health services, and reductions in the structural inequalities that produce criminalisation and ill-health.