The Effect of Imprisonment on Mental Health
36 f MENTAL HEALTH By W. F. ROPER, M.B., B.S.(London) Principal Medical Officer, H.M. Prison, Wakefield The purpose of this paper is to give a brief review of the effect of imprisonment on mental health. Owing to the time factor much must perforce be left out which ought to be inserted, and as it is impossible to go into any detail, the most that can be hoped is to give a broad general survey.
The effect of imprisonment on any particular person is the product of many factors, the most important of which are his physical health, the length and nature of the sentence, the course of external events which are of importance to him, his management whilst a prisoner, and finally, and most importantly, the attitude which he displays towards his conviction and sentence.
Let us now examine these factors in order.
Physical Health
The effect of imprisonment on physical health is, in general, good. Prison provides a regular life and a full range of medical treatment, either from internal resources or by arrangement with outside agencies. Complaints of ill health at the time of discharge are rare, and there is an average gain in weight of about 5 lbs. with a general convergence on the normal weight. The obese lose weight and the lean gain. A fair number of repair operations ?as for a hernia?are done with the general object of fitting a man physically for work on his release.
The efficiency and thoroughness of the general medical work done has important repercussions on the attitude of the prisoner. If he feels that he can and does receive efficient medical attention, he is more inclined to be receptive to anything in the nature of general or psychiatric counselling, and much can be done with a man whose pain or discomfort one has been able to relieve, just as much can be done by the respected general practitioner in ordinary life. There is a difficulty, however, in that some prisoners, particularly some recidivist prisoners, are apt to try to exploit any disability which they have in order to gain some ulterior purpose, such as avoidance of work which they do not like, or escape from disciplinary penalties. It is very understandable that they should do this, but it is important that they should not get away with it with any frequency; if they do, the idea that they are clever people capable of fixing things to their advantage is reinforced; in short they are confirmed in that kind of cunning which has led to their offence. The art of dealing with these men lies in being able to expose their ulterior motive without animosity. If this can be done, this type of intrigue dies away and more straightforward and mutually trusting relationships are possible; it is just this sort of relationship which is to be desired in order that the prisoner may not feel that he is in another camp and so proceed to deceit and stratagem in order to get what he wants.
One of the most encouraging aspects of prison, to my mind, is the way in which many psychosomatic illnesses clear up. In peptic ulcer, for example, the usual evolution is that for the first week or so after conviction, the prisoner will ask for and receive a special diet, together with alkaline powder; he then gives up his diet and shortly afterwards forgets to collect his alkaline powder. His symptoms have gone, presumably because the emotional tension which produced the somatic lesion has gone. For prison means security of a kind and therefore relaxation. A not infrequent remark on discharge is, ” it is a pity that 1 had to come to prison to get my ulcer cured “. In a like way, but to a lesser degree, enuresis, allergic diseases and hypertension tend to clear up, presumably for the same reasons. This kind of fortunate result appears to be somewhat more frequent now than it was 20 years ago, and it reflects the general improvement in the flexibility of prison discipline which has taken place during that time.
Length and Nature of Sentence For the prisoner, the sentence divides itself into three periods?a beginning, a middle and * Paper given at a Specialist Meeting of the Institute for the Scientific Treatment of Delinquency held in connection with the International Congress on Mental Health, London, August 20th, 1948. an end. In the beginning he is casting his mind back to times and opportunities past, in the middle he is concerned mainly with the present and its possibilities, in the end he is thinking of his approaching release and is chiefly concerned to avoid anything which will defer it.
Both the beginning and the end are relatively unstable periods in which the mind is preoccupied with external events, past or future, and they are very good times for the discussion of the past or future with the prisoner, but very bad times for training, because the mind is not ?n intra-mural events.
It follows that a short sentence, one of six months or so, which has no middle, is useless for training purposes and is regarded with disfavour by prison authorities, though still extensively used by the courts.
In the medium sentence of about two years, there is a distinct middle period when repining is over and release is too far ahead to claim much attention. To the prisoner this seems a static period which he often considers a futile one; he is apt to say that he is wasting his time and that he would be better at liberty earning his living and keeping his family. But it is in this Period that the lessons he has learnt consolidate and fix themselves, and it is the most favourable Period from the penological point of view. Long sentences, say of six years and upwards, seem all middle and may lead to a certain disinterest and boredom in those men who are unable to find real interest in their work. It is usual to find means?as by transfer to other and different prisons?to break up this period and vary the monotony. In this way, what has keen called ” prison rot” is avoided and mental deterioration is not now seen. In times gone by, what were called prison psychoses did occur, but they must now be very rare. In the English system all sentences except life sentences are determinate, and the man concerned can reckon up the date of his release. As soon as he has done so, a kind of time clock seems to settle itself in his mind, and it is a bad Policy to suggest to him that the timing may be revised; such a suggestion leads to considerable unsettlement, and if the hope is dashed it seems to him almost like beginning the sentence again. This is a thing to remember when advocating an indeterminate sentence or frequent revision of sentence.
External Events
Although the body of the prisoner is in prison, his mind is free and will often return to his family and his friends; bad news from them will often cause distress, which is the greater since he can do nothing about it. In general, both prisoners and their friends’ are reasonable about this and give no more currency to bad news than they must. But it not infrequently happens, chiefly between husband and wife, that a vicious circle is set up, in which self-pitying or angry letters evoke their counterpart and bring about anxiety symptoms, usually of a somatic nature. It is always worth while enquiring of a prisoner who presents himself with vague complaints, whether he has had bad news from home. Often he has, and the discussion of his anxiety rather than the treatment of any somatic condition is what he requires; indeed, it is often a great mistake to give medical treatment in these cases, lest the idea of a somatic disorder fix itself in the mind; it is not appreciated how much harm the inappropriate bottle of medicine can do. If this facile method of temporary disposal is avoided and the actual problem tackled, much good work can be done.
The most difficult reactions occur in prisoners of hysteroid personality, of whom there are many. These people welcome the opportunity for histrionic display and make the worst of their troubles rather than the best. Actually the effect in these demonstrative cases is shallow and the demand soon arises for some special privilege or other?that is to say, there is a positive trend towards personal profit which has to be carefully and tactfully parried lest the disposition to show self-pity for profit be reinforced. Any such reinforcement is greatly to be deplored; nothing saps character so quickly and so destructively as distress reinforced and exploited for profit. Considerable numbers of former psychiatric patients arrive in prison who have obtained fugitive advantage from the display of psychopathic behaviour, and they have trained on from that point to become useless to themselves and others. A major service can be rendered to these men if this training can be reviewed in prison by gently but firmly demonstrating to them that it is better to keep trying, and by removing the idea that a diagnosis of psychopathic personality is a licence to behave irresponsibly. If this idea can be removed, the personality deviation often clears up also, and is revealed as something which has been learned and not as something innate. A considerable number of these cases do clear up in prison and the prognosis as to recidivism improves accordingly.
It is important to do what one can to tidy up the prisoner’s relationship with outside persons and groups, because his fate on release depends so much on whether he goes out in a state of mind which enables him to cohere to a socially desirable group. If he is acceptable to such a group and recaptures a sense of belonging to it, that constitutes the greatest guarantee for future mental health and future good behaviour. The lonely man, the man on the outskirts of a group, or the man who is only at his ease in a socially undesirable group has not the same restraint on him; he can contemplate and do things that would be unthinkable to one fully integrated in a satisfactory social group.
Attitude of the Prisoner
The most important factor in deciding the effect which imprisonment will have on a man, is the attitude finally adopted towards conviction and sentence. If the attitude of acceptance with regret occurs spontaneously or can be induced, the outlook is good, both as regards contentment during confinement and good b’ehaviour on release. The point one wants to reach is that at which the sense of guilt is sufficient to make the prisoner feel that he has deserved more or less what he has got, without there being so much over as to set up defence reactions.
Only a minority of prisoners show outward signs of rejection of the approximate justice of conviction and sentence, and they are a fairly hopeful group provided their reactions can be properly managed.
The disquieting group are those who accept their fate without much reaction. The bulk of them are drifters who think of little beyond the moment, and readily follow the lead of others. Their fate depends upon the environment into which they fall and upon the character of those who trouble to lead them. Imprisonment has little effect upon these men; in their earlier days they did not want to return, but do little to prevent coming back; in their later days they often do not trouble whether they come back or not, and are even glad to do so when they are up against difficulty.
A smaller group is that of the professional criminals who accept confinement as one of the risks of their trade, just as a coal-miner might accept the risk of injury in the digging of coal. They do not want to return to prison any more than the miner wants to be injured, but they feel that the profit they make is sufficient to justify the risk, and they reject with contempt any suggestion that they should settle down to live on a modest wage. Their attitude is often rationalized by allegations that, in any case, society will not give them a square deal; this makes the condition an obdurate one for which little can be done.
On discharge these men return to criminal groups and there is little hope for them so long as this is so.
Management
The great attraction of prison work is the scope given for the art of man-management; it is a good career for those who like the management of men, a poor one for those who do not. The difference between people in this respect is very great; with the same group, one man may have peace and progress, another discord and discontent.
The roots of crime go back to faulty piersonal relationships in early life, and these faulty relationships come into evidence again quite strongly when a prisoner is again reduced to a position of dependence. A flexible attitude is required in which both kindness and firmness are combined; the object is to restrain the fault without feeling or showing dislike of the person.
Prisoners of all kinds react very well to the right mixture and there are very few who cannot be brought to tolerate their imprisonment well if properly handled.
It does not necessarily follow that the effect produced will endure after release, but it will often do so and thus enable the man concerned to tolerate the give and take of everyday life in a way which was formerly impossible to him. This is the fundamental task of prison treatment, and the quality of the staff determines the degree of success which can be achieved. However, there must be more than this if a secure result is to be achieved. There has to be some grasp of the use and value of life, so that the released prisoner may have some standard by which to live. Not a great deal has been done in this way as yet, but the moral idea cannot be neglected. It will have to be faced, bearing in mind that it is useless to try to thrust any moral system upon the prisoner; his own ideas have to be brought out and developed; these he can accept, but he will defend himself against ideas which are thrust upon him, or accept them only as a hypocrite does.
The Stereotyped Idea of Prisons
One great difficulty under which prisons labour, is the popular idea that they are nasty places for nasty people; a stereotyped idea of that sort, based on the prisons of many years ago, persists, and prepares a ready credence for biased evidence. The popular stereotype persists because it is thought convenient to have something to cause fear to intending criminals, although it is doubtful whether this kind of deterrence is worth much; a threat is often taken as a challenge.
Another reason for the persistence of the stereotype is the need found by novelists and dramatists to have some limbo into which they may consign their villains or their heroes. It is convenient for them to preserve old traditions, and difficult for the public to escape from them, so long as they are continually thrust upon them by the most dramatic pens of their time. The effect of this, so far as the prisoner is concerned, is that the public are apt to regard him in an ambivalent way. Considered as a criminal, he is unduly detested, otherwise he could not be sent to a detestable place; considered as a prisoner, he may be unduly pitied, since he has been sent to a detestable place. This may thrust the social role of villain or victim upon the prisoner, and unless he keeps his sense of proportion, as fortunately most of them do, he may settle all too easily into the one role or the other, or both by turns, and either is a role which could hardly be other than anti-social.
It is much to be hoped that the stereotyped idea of prison will undergo that same change as has that of the asylum, when it was transformed into the mental hospital. The point is an important one; just as it is now not so socially difficult for a released mental patient to find a place in the world as it was in times gone by, so, if a better idea of prison becomes current, it will not be so socially difficult for prisoners after their release. After all, as we have seen, the great majority of them remain honest and reliable after their first experience of prison.
Summary
Let us now summarize the points made, they are:
1. That the physical health of prisoners on discharge is satisfactory, and that the commonly favourable evolution of psychosomatic disorders argues in favour of a relief of emotional tension in prison. 2. That short sentences provide little effect save unsettlement, and that long sentences produce no deleterious effect if properly managed. Indeterminacy of sentence brings unsettlement.
3. That the fate of prisoners on release depends very much on their ability to cohere to a satisfactory social group and upon the existence of such a group ready to receive them.
4. That the effect of imprisonment depends mainly on the attitude towards his fate, taken by the prisoner. The attitude of acceptance with regret is the desideratum. 5. That the right handling of the prisoner is a potent factor in bringing about this right attitude, and that right handling means, above all, the ability to restrain the fault without disliking the person.
6. That the social result of prison treatment is good beyond the general recognition.
7. That the stereotyped idea of prison as a nasty place for nasty people tends to thrust upon the prisoner the role of villain or victim, either of which is unprofitable; and that it will be a good thing if this stereotype can be replaced by one closer to the truth.
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