- Email: [email protected]
Prison*
Prison 217 interact to influence primate CNS function. Molecular Psychiatry 7, 118–122. Champoux, M., Bennett, A., Shannon, C., et al. (2002). Serotonin transporter gene polymorphism, differential early rearing and behavior in rhesus monkey neonates. Molecular Psychiatry 7, 1058–1063. Higley, J. D., Suomi, S. J. and Linnoila, M. (1991). CSF monoamine metabolite concentrations vary according to age, rearing and sex, and are influenced by the stressor of social separation in rhesus monkeys. Psychopharmacology 103, 551–556. Newman, T. K., Syagailo, Y., Barr, C. S., et al. (2005). Monoamine oxidase A gene promoter variation and
rearing experience influence aggressive behavior in rhesus monkeys. Biological Psychiatry 57, 167–172. Sa´nchez, M. M., Ladd, C. O. and Plotsky, P. M. (2001). Early adverse experience as a developmental factor for later psychopathology: evidence from rodent and primate models. Development and Psychopathology 13, 419–449. Suomi, S. J. (1987). Genetic and maternal contributions to individual differences in rhesus monkey biobehavioral development. In: Krasnegor, N. A., Blass, E. M., Hofer, M. A. & Smotherman, W. P. (eds.) Perinatal development: a psychobiological perspective, pp. 397–420. New York: Academic Press.
Prison D L Whitehead and A Steptoe University College London, London, UK ã 2007 Elsevier Inc. All rights reserved. This article is a revision of the previous edition article by J Griffith and A Steptoe, volume 3, pp 241–246, ã 2000, Elsevier Inc.
Scope of the Problem Prison Inmates Prison Staff Limitations and Conclusion
Glossary Bullying
Role conflict
Depersonalization Punitive approach
Rehabilitative approach
The act of repeatedly intimidating a weaker person by the real or threatened infliction of physical, verbal, or emotional abuse. A form of social conflict that takes place when the person is forced to take on two different and incompatible roles at the same time. A feeling of detachment or estrangement from the self, in which the individual senses a loss of personal identity. The perspective on incarceration which reflects the belief that inflicting punishment on an individual will act as a deterrent and decrease the likelihood of the crime being repeated. The perspective on incarceration which reflects the belief that an individual can be retrained to function appropriately in society through supportive educational programs in prison.
Scope of the Problem In 2005, 714/100 000 U.S. residents were incarcerated in prisons and jails, a rate that had risen by 5.0% over the previous 5 years. Bureau of Justice statistics in the United States indicate that if current incarceration rates remain unchanged, an estimated 1 out of every 20 people (5.1%) will serve time in prison during his or her lifetime. U.S. incarceration rates are very much higher than in Europe, where there are wide variations between countries. Southern European countries have a relatively low rate of 80/100 000, compared with 184/100 000 in eastern and central Europe; rates in the United Kingdom fall in the middle, at 139/100 000 in 2005. There is a very much higher incarceration rate among men than women, and more than 90% of convicts are men. However, one important change over recent years has been the rate of growth of the number of female inmates, which has outstripped that of men. The U.S. female prison population grew by 5.0% annually from 1999 to 2004, compared with a growth rate of 3.3% in the male population. Research has not kept pace with this change, and until recently most studies were conducted on the male inmate population. Overall, inmates are more likely to be young, single, and less well educated than the population at large. Ethnic minority groups are substantially overrepresented in the prison population. In 2004, 12.6% of Black American males in their late twenties were incarcerated, compared with 3.6% of Hispanic males and 1.7% of White males. Imprisonment is one of the most stressful human experiences and figures high in all comparisons of negative life events. A combination of environmental
218 Prison
and personal deprivation in unpleasant and often frightening circumstances can lead to the perception of extreme stress. Factors such as adherence to a strict daily routine, close living proximity, loss of control over life course, and loss of freedom have all been identified as causing psychological distress. Interpersonal relationships with prison officers and other inmates and the strain on relationships with friends and family are also causes of psychological disturbance. Associated factors such as financial hardship, coping with guilt, and dealing with aggressive fellow inmates can contribute to stress-related problems in prisoners. Prison staff also report a range of stressors associated with the job. The main stressors are the maintenance of order and the risk of loss of control over hostile inmates, combined with the lack of support from supervisors and society. The difficulty in balancing the responsibility for the welfare of prisoners with the responsibility for security leads to conflicting work demands.
Prison Inmates Sources of Stress
A number of studies have identified a range of stressors reported among inmates. These fall into several categories. Personal relationships The separation from partner and family has been cited as one of the main stressors of serving time in prison. For female inmates, the separation from their children is particularly stressful. The majority of women in prison are mothers and many are also heads of households. The separation from their children has been found to be associated with a wide range of feelings such as guilt, anxiety about welfare of the children, and fear of losing close attachments to the children. This may be one reason why women have been found to suffer more emotional distress in prison than men. The effects of separation are also evident from the finding that married men show higher levels of distress than single men. Being deprived of intimacy and worrying about the welfare of their family are also significant. The lack of confiding relationships and being denied meaningful contact with the opposite gender may create new anxieties regarding sexual identity. Coming to terms with such a mixture of emotions can pose a risk to mental health. Establishing friendships within prison is an important aspect of adaptation. One study of young inmates found that social support and the ability to confide in
friends in prison were major predictors of psychological well-being. The fear of rejection by other inmates and social isolation can cause heightened anxiety, especially in the initial stages of incarceration. However, in many cases such concerns are ill-founded because one study found that prisoners tend to receive more social support from other prisoners than they had anticipated. Economic factors The loss of income associated with incarceration can be a major problem for prisoners and their families. Men who report financial hardship experience greater distress than those who are financially secure. Prison environment Lack of privacy and crowding are serious problems within the prison environment. In many countries, prisons are filled beyond capacity. In the United Kingdom, for example, the Home Office released figures in 2005 that indicated a 106% occupancy rate across all prison service establishments. When personal space is threatened, angry or defensive reactions may result. Research has shown that men living in single cells report liking their accommodation more and perceive themselves having greater control than inmates living in multiple occupancy cells or dormitories. Violence is a serious concern for many inmates, and many have long-lasting fears of attack that may be associated with sustained neuroendocrine and autonomic activation. The rates of sexual and physical assault are difficult to estimate because much abuse goes unreported. Bullying and favoritism by staff are also found in many institutions. Other aspects of the prison environment that can be sources of stress are noise levels, lack of control over lighting, physical discomfort arising from extremes of heat and cold, lack of contact with the natural environment, absence of intellectual stimulation, and constraints on physical activity. One issue that is problematic is the pressure not to show evidence of distress. Often emotions associated with stress such as fear, grief, and depression are not admitted and are hidden from staff and other inmates. This hinders the analysis and solution of stress-related problems. Time Course of Imprisonment
Certain sources of stress are more evident at different stages of imprisonment. Three phases of a prisoner’s career have been identified. Initial phase This is the most stressful period when the inmate first encounters prison life. First-time
Prison 219
offenders are particularly vulnerable due to the loss of liberty and separation from friends and family. This stage is often characterized by feelings of denial followed by anxiety and depression, although other emotions such as shock, fear, isolation, grief, and anger are also reported frequently. The adjustment period typically lasts for the first 4–6 weeks of confinement. It is at this stage that many suicide attempts are made. Middle phase During the middle stage of the sentence, the focus is on the prison community. Friendships are established, and some inmates experiment with drugs and gay sex. Mandatory drug testing has been introduced in many countries; despite efforts to prevent the importation and use of illegal drugs into prisons, the problem is common. In 2001, a UK prison survey found that 19% of inmates reported using cannabis in the previous month, and 13% reported using opiates. Although drug use is prevalent, a smaller proportion of inmates use drugs while in prison than did prior to incarceration. Final phase Some convicts become preoccupied with their release in the final few weeks of their prison terms. Apprehension about cultural changes after long sentences is coupled with worry about the attitudes of friends and neighbors and the need to reestablish family relationships and reenter employment. Health and economic disparities that existed before incarceration are intensified following release, because access to jobs, health insurance, public housing and health benefits may be limited to exprisoners, particularly in the United States, and disproportionately in ethnic minority groups. Thus incarceration continues to exert effects leading to increased stress and poor health even after release. Responses to the Stress of Prison Life
The stress experienced by prisoners has been measured in several ways: by self-report measures of mood, well-being, and mental health; by the incidence and prevalence of physical health outcomes, mental health outcomes, and physiological indicators of stress; and by the most powerful indicator of hopelessness and despair, suicide. The investigation of the psychological state of inmates and stress-related effects in prisons faces a number of methodological challenges. First, assessing the impact of incarceration is complicated by limited knowledge about the prior health and well-being of inmates. Many studies of stress in prisons that use outcomes such as hospitalization for mental illness
during incarceration are problematic in that incident psychopathology, that is, new onset mental illness, may be difficult to distinguish from prevalent psychopathology, which has been consistently demonstrated as having higher rates in prisoners. Longitudinal studies following prisoners from the first days of incarceration are the only way of studying the emergence of stress resulting from the prison environment rather than ongoing stress from psychosocial disadvantage or existing psychopathology that entails greater risk of conviction in the first place. Second, the general population is a poor comparison group when assessing the relative prevalence of stress-related disorder in prisoners. Many individuals sent to prison have histories of psychological problems and drug abuse prior to sentencing. Inmates also tend to come from low-income families, to be unemployed, and to have limited education and therefore may have previously encountered negative life events, inadequate health care, and poor living conditions. Drug and alcohol problems frequently precede incarceration; a survey of convicts in state prisons in the United States indicated that 50% of those convicted of violent crimes were under the influence of drugs or alcohol at the time of the offense, and in 1993 drug offenders accounted for 61% of inmates in federal prisons. The high prevalence of some problems among inmates cannot, therefore, be attributed to the prison experience and is confounded by considerable preexisting psychosocial disadvantage in this group. Nevertheless, anxiety, depression, and complaints of fatigue, sleeplessness, headache, and backache are common. In one study of female convicts, nearly half met the diagnostic criteria for posttraumatic stress disorder (PTSD), and major depression was more prevalent than in the general population. A study of a representative sample of imprisoned juvenile delinquents in California found that half experienced PTSD, with many having witnessed or been involved in traumatic violent episodes. The prevalence of infectious disease, sexually transmitted disease, and tuberculosis is also high compared with the general population. Substantial weight gain has been recorded among female inmates, resulting from the combination of the sedentary lifestyle and the availability of energy-dense high-fat foods. A recent British study investigating subjective health status in female inmates addressed the confounding by lower socioeconomic status in prisoners. Using a comparison group of women from lower-socioeconomic-status sectors of the community, a comparable level of physical health complaints and a greater level of mental health complaints were found in prisoners.
220 Prison
Blood pressure has been found to be elevated in prison inmates compared with matched controls and to increase with the duration of confinement and the degree of crowding in prison. One particularly impressive study used a quasi-experimental approach by measuring the blood pressure of male convicts assigned to individual cells, four-bed cells, and larger dormitories in a medium-security prison. Blood pressure increased to a greater extent in men who were transferred to multiple-occupancy cells and dormitories compared with those who were transferred to other individual cells. However, a third methodological problem with studies of physiological stress markers is that prison studies have not kept pace with recent advances in measuring such markers as ambulatory blood pressure, cortisol, catecholamines, and inflammation. One notable exception is the Copenhagen Solitary Confinement study, which assessed changes in mood, orientation, and serum cortisol during the first 3 months and compared prisoners kept in solitary confinement (SC) with prisoners in shared cells. Although anxiety, depression, and morning cortisol levels were reduced over time in the non-SC group, such reductions did not occur in the SC group, indicating a lack of adaptation to the prison environment. Many physiological markers of stress are good prognostic indicators of health problems such as autoimmune and cardiovascular diseases, and therefore it may be fruitful to pursue this avenue. International surveys have found that the suicide rate in prison is between 3 and 11 times greater than that of the general population, with a reported fivefold increase compared with the UK general male population from 1978 to 2003. Most suicides take place within the first few weeks of incarceration and are more common in crowded institutions than other prisons. High rates have been recorded among prisoners on remand and those convicted of murder and serving life sentences. Although suicide is most frequent in young males, self-harm is highly prevalent in female inmates, and recent UK Home Office statistics report a rate of 58.7%. Unlike the pattern in the general population, depression is not a common diagnosis at the time of death, although about onethird of male suicides had some form of psychiatric treatment in the past. Drug or alcohol dependence can be found in a substantial proportion of these cases. There is also evidence for a European trend toward reinstitutionalization of those with mental health problems in recent years – but in prisons rather than in psychiatric hospitals. A systematic review of prevalence studies in Western countries in 2002 found an overall prevalence of 3.7% for psychotic disorders (10% for major depression), representing a two- to
fourfold increase in mental illness compared with the general population. It is likely that U.S. prisons and jails hold up to twice as many individuals with mental illness than do state psychiatric hospitals; the prison system is not well equipped to support these individuals. Characteristics of the Individual Convict
Some individuals adapt to incarceration better than others and survive even lengthy prison terms without experiencing high levels of distress. Older convicts tend to have more friends in prison, to have more contact with family and friends outside, and to report greater psychological well-being than younger individuals. A recent UK Home Office report, however, drew attention to the often overlooked but growing population of prisoners aged 60 and over. Although physical health problems in this cohort are often well provided for, psychiatric problems, in particular major depression, are not well treated. Political demand for longer sentencing for some crimes means that this older cohort will continue to provide an ongoing challenge for prison services. As noted earlier, higher levels of anxiety and depression are found in female than in male prisoners, although it is not clear whether this is a specific response to imprisonment or reflects the more general difference in distress found in the adult population at large. Members of ethnic and religious minorities suffer more than members of the majority because prejudice and cultural isolation are added to the other sources of stress present in prison. In the United States, it has been noted that White prisoners are more likely to attempt and complete suicide than African American prisoners, but the reasons are poorly understood. One suggestion is that being raised in the tough conditions experienced by many African Americans makes adults more resilient to the pressures of prison life. Alternatively, because proportionately more Black than White Americans are incarcerated, they may come from a broader spectrum of society; White inmates may include a higher proportion of marginalized, psychologically vulnerable individuals. Methods of Reducing Stress among Inmates
The management of stress in prison inmates involves several different levels of intervention. Medical and psychiatric services have an important role in preventing suicide and self-harm, in managing drug dependence, and in treating other psychiatric and neurological problems. Support is often hampered by the reluctance of inmates to divulge personal information to authorities or to reveal weakness. Training prison staff more generally in suicide prevention
Prison 221
is also important. A recent public health initiative in Texas prisons led to improvements in health outcomes, and Telemedicine, allowing rapid access to telephone consultations for physical and mental health problems, proved to be a novel and effective way of delivering health care. At a more general level, education, training, and other initiatives help build prisoners’ self-esteem and confidence in their ability to adapt to civilian life after release. Increasing physical activity and exercise may also be beneficial. Studies have found that inmates who have a job detail or are on work-release programs show less evidence of stress than those who are not active. Finally, changes at the institutional level may be warranted. It is likely that modifications of prison regimes in relation to aspects such as staff attitudes, privileges, training opportunities, and relocation of inmates to serve their terms near their families could play a key role in alleviating stress among inmates. However, the reality is that stress does not figure highly among the concerns of prison administrators or politicians, some of whom would argue that prison should be stressful.
Prison Staff
United States, where ethnic minorities are grossly overrepresented among inmates. Some differences have been observed between new and long-serving staff. Newly appointed staff members report a lack of support from supervisors and a concern with lack of control over the working environment as particularly problematic. Those who have been working for longer periods are more troubled by the absence of support and respect from society and the lack of variation in the job. The combination of tedium associated with mundane day-to-day activities and the pressure to maintain vigilance in order to react quickly to high-risk incidents appears to be especially stressful. Many prison officers believe that the responsibilities for security and the welfare of inmates are incompatible obligations. A recent meta-analysis of factors predicting work-related stress revealed an interesting effect of punitive versus rehabilitative attitudes – officers in the United States who endorsed rehabilitative attitudes experienced greater stress, whereas those in Canada with stronger punitive attitudes were more stressed. This suggests that when individuals’ beliefs about their role are at odds with the ethos of the prison service in a particular country, stress and conflict are the result.
Sources of Stress
Research on prison staff members finds that many of the issues cited in the general literature on occupational stress are relevant for them as well. As with other jobs, factors such as work demands, role conflict, low control, and poor social support emerge as relevant. Thus, symptoms of psychological distress and job dissatisfaction are greater among correctional officers who report high work demands coupled with low control and low support from management and colleagues. However, these problems are exacerbated by the peculiar requirements of working in prison. Prison officers cite the conflict of responsibilities in the job as an underlying source of stress and dissatisfaction. On the one hand, prison staff members are responsible for the welfare of inmates and for the maintenance of their physical and psychological well-being. On the other hand, they are required to maintain security and protect the public from the dangerous and sometimes violent convicts. The prison environment is often volatile, with a high risk of aggressive behavior from inmates. Confrontations with inmates and the threat of physical danger are cited as major sources of stress, irrespective of the age and gender of staff members. Ethnic minority prison officers have been found to experience lower stress levels, especially in the
Outcomes of Stress
High rates of sick leave for both minor complaints (fatigue, headaches, and indigestion) and physical health problems (high blood pressure and peptic ulcers) occur among prison staff. In one study, the rates of coronary heart disease, hypertension, and ulcers were found to be greater among correctional officers than a comparable sample of police officers. The divorce rate in correctional officers is reported as being twice that of blue- and white-collar workers in general. Job dissatisfaction is coupled with the increased prevalence of divorce in this occupational group. The rates of sick leave are greater among staff members in maximum security prisons and in prisons with many drug users than in other correctional institutions. There is a greater prevalence of psychological distress in prison officers. Much of the research has focused on burnout, with male and female staff members reporting similar high levels of depersonalization and emotional exhaustion. Self-reported anxiety and depression are also elevated compared with the general working population. Female officers are more likely to take sick leave than male officers, but this pattern may result from family demands rather than different levels of stress at work.
222 Prison Methods of Reducing Stress in Prison Staff
It has been noted in the research literature that many prison officers do not perceive themselves to be stressed but, rather, see their colleagues as being stressed. Pressure not to show the effects of stress may be particularly evident in a male-dominated environment where there is fear that any sign of weakness will be exploited by the inmates. Admitting to feeling stressed may be interpreted as an inability to cope and therefore as not being strong enough for the job at hand. Alternatively, some prison officers may not be able to identify the personal effects of stress in themselves. This suggests that education about stress and how it can be managed may both benefit prison staff members directly and help them to identify the repercussions of stress in inmates. A number of studies have found that exercise and fitness programs have positive effects. One investigation involving a 6-week strength and aerobic program showed reductions in body weight, skinfold thickness, and cholesterol levels, together with beneficial changes in smoking, alcohol consumption, sleep, nutritional habits, and stress tolerance. Consultation and efforts to enhance social support at work have been found to counteract the effects of stress. Factors such as goal consensus among staff, a proactive management style, and increasing of decision latitude can be incorporated into the working environment.
Limitations and Conclusion There are a number of limitations in the studies that have been carried out thus far about stress in prisons. Most have been cross-sectional in nature, identifying associations between aspects of prison experience and diminished well-being, and the causal sequence is uncertain. Longitudinal designs and data on inmates prior to imprisonment are important in the assessment of the impact of stressors because some apparent effects of incarceration may be the direct consequences of prior experience. The nature of the offense, family situation, and previous physical and mental health are all important factors that should be taken into account. Also, the civilian groups with which prisoners are compared in many studies may not be matched appropriately in terms of background characteristics. The generalizability of results across populations is uncertain. The majority of studies have been conducted on White male adults and may not be relevant to women, ethnic minorities, and juveniles. This is
not mere tokenism because it is apparent from the limited information available that the experience of prison is very different for people of different backgrounds and cultures. The applicability of findings to different prison systems must also be questioned. Justice systems in the United Kingdom and other European countries differ greatly from the U.S. system, and countries also vary in the extent to which individuals with serious psychiatric histories are found in prison. The application of management suggestions derived from one system must be reviewed carefully before their implementation elsewhere. Nevertheless, the data do indicate that imprisonment is severely stressful for many inmates and that work within the prison system is also associated with higher rates of stress-related dysfunction than comparable jobs. Education and the implementation of specific stress-management programs may be beneficial to both groups and may help ensure that stress in prison is confined within tolerable limits.
See Also the Following Articles Burnout; Crowding Stress; Prisoners of War; Racial Harassment/Discrimination; Workplace Stress.
Further Reading Andersen, H. S. (2004). Mental health in prison populations: a review. Acta Psychiatrica Scandinavica 110(supplement 424), 5–59. Andersen, H. S., Sestoft, D., Lillebaek, T., et al. (2003). A longitudinal study of prisoners on remand: repeated measures of psychopathology in the initial phase of solitary versus nonsolitary confinement. International Journal of Law and Psychiatry 26, 165–177. Cooke, D. J., Baldwin, P. J. and Howison, J. (1993). Psychology in prisons. London: Routledge. DeRosia, V. R. (1998). Living inside prison walls: adjustment behavior. Westport, CT: Praeger. Hayes, L. M. and Blaauw, E. (eds.) (1997). Special issue on prison suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention 18(4). Dowden, C. and Tellier, C. (2004). Predicting work-related stress in correctional officers: a meta-analysis. Journal of Criminal Justice 32, 31–47. Lindquist, C. H. and Linquist, C. A. (1997). Gender differences in distress: mental health consequences of environmental stress among jail inmates. Behavioral Sciences & the Law 15, 503–523. Ostfeld, A. M., Kasl, S. V., D’Atri, D. A. and Fitzgerald, E. F. (1987). Stress, crowding and blood pressure in prison. Hillsdale, NJ: Lawrence Erlbaum. Paulus, P. B. (1988). Prison crowding: a psychological perspective. New York: Springer-Verlag.
rearing experience influence aggressive behavior in rhesus monkeys. Biological Psychiatry 57, 167–172. Sa´nchez, M. M., Ladd, C. O. and Plotsky, P. M. (2001). Early adverse experience as a developmental factor for later psychopathology: evidence from rodent and primate models. Development and Psychopathology 13, 419–449. Suomi, S. J. (1987). Genetic and maternal contributions to individual differences in rhesus monkey biobehavioral development. In: Krasnegor, N. A., Blass, E. M., Hofer, M. A. & Smotherman, W. P. (eds.) Perinatal development: a psychobiological perspective, pp. 397–420. New York: Academic Press.
Prison D L Whitehead and A Steptoe University College London, London, UK ã 2007 Elsevier Inc. All rights reserved. This article is a revision of the previous edition article by J Griffith and A Steptoe, volume 3, pp 241–246, ã 2000, Elsevier Inc.
Scope of the Problem Prison Inmates Prison Staff Limitations and Conclusion
Glossary Bullying
Role conflict
Depersonalization Punitive approach
Rehabilitative approach
The act of repeatedly intimidating a weaker person by the real or threatened infliction of physical, verbal, or emotional abuse. A form of social conflict that takes place when the person is forced to take on two different and incompatible roles at the same time. A feeling of detachment or estrangement from the self, in which the individual senses a loss of personal identity. The perspective on incarceration which reflects the belief that inflicting punishment on an individual will act as a deterrent and decrease the likelihood of the crime being repeated. The perspective on incarceration which reflects the belief that an individual can be retrained to function appropriately in society through supportive educational programs in prison.
Scope of the Problem In 2005, 714/100 000 U.S. residents were incarcerated in prisons and jails, a rate that had risen by 5.0% over the previous 5 years. Bureau of Justice statistics in the United States indicate that if current incarceration rates remain unchanged, an estimated 1 out of every 20 people (5.1%) will serve time in prison during his or her lifetime. U.S. incarceration rates are very much higher than in Europe, where there are wide variations between countries. Southern European countries have a relatively low rate of 80/100 000, compared with 184/100 000 in eastern and central Europe; rates in the United Kingdom fall in the middle, at 139/100 000 in 2005. There is a very much higher incarceration rate among men than women, and more than 90% of convicts are men. However, one important change over recent years has been the rate of growth of the number of female inmates, which has outstripped that of men. The U.S. female prison population grew by 5.0% annually from 1999 to 2004, compared with a growth rate of 3.3% in the male population. Research has not kept pace with this change, and until recently most studies were conducted on the male inmate population. Overall, inmates are more likely to be young, single, and less well educated than the population at large. Ethnic minority groups are substantially overrepresented in the prison population. In 2004, 12.6% of Black American males in their late twenties were incarcerated, compared with 3.6% of Hispanic males and 1.7% of White males. Imprisonment is one of the most stressful human experiences and figures high in all comparisons of negative life events. A combination of environmental
218 Prison
and personal deprivation in unpleasant and often frightening circumstances can lead to the perception of extreme stress. Factors such as adherence to a strict daily routine, close living proximity, loss of control over life course, and loss of freedom have all been identified as causing psychological distress. Interpersonal relationships with prison officers and other inmates and the strain on relationships with friends and family are also causes of psychological disturbance. Associated factors such as financial hardship, coping with guilt, and dealing with aggressive fellow inmates can contribute to stress-related problems in prisoners. Prison staff also report a range of stressors associated with the job. The main stressors are the maintenance of order and the risk of loss of control over hostile inmates, combined with the lack of support from supervisors and society. The difficulty in balancing the responsibility for the welfare of prisoners with the responsibility for security leads to conflicting work demands.
Prison Inmates Sources of Stress
A number of studies have identified a range of stressors reported among inmates. These fall into several categories. Personal relationships The separation from partner and family has been cited as one of the main stressors of serving time in prison. For female inmates, the separation from their children is particularly stressful. The majority of women in prison are mothers and many are also heads of households. The separation from their children has been found to be associated with a wide range of feelings such as guilt, anxiety about welfare of the children, and fear of losing close attachments to the children. This may be one reason why women have been found to suffer more emotional distress in prison than men. The effects of separation are also evident from the finding that married men show higher levels of distress than single men. Being deprived of intimacy and worrying about the welfare of their family are also significant. The lack of confiding relationships and being denied meaningful contact with the opposite gender may create new anxieties regarding sexual identity. Coming to terms with such a mixture of emotions can pose a risk to mental health. Establishing friendships within prison is an important aspect of adaptation. One study of young inmates found that social support and the ability to confide in
friends in prison were major predictors of psychological well-being. The fear of rejection by other inmates and social isolation can cause heightened anxiety, especially in the initial stages of incarceration. However, in many cases such concerns are ill-founded because one study found that prisoners tend to receive more social support from other prisoners than they had anticipated. Economic factors The loss of income associated with incarceration can be a major problem for prisoners and their families. Men who report financial hardship experience greater distress than those who are financially secure. Prison environment Lack of privacy and crowding are serious problems within the prison environment. In many countries, prisons are filled beyond capacity. In the United Kingdom, for example, the Home Office released figures in 2005 that indicated a 106% occupancy rate across all prison service establishments. When personal space is threatened, angry or defensive reactions may result. Research has shown that men living in single cells report liking their accommodation more and perceive themselves having greater control than inmates living in multiple occupancy cells or dormitories. Violence is a serious concern for many inmates, and many have long-lasting fears of attack that may be associated with sustained neuroendocrine and autonomic activation. The rates of sexual and physical assault are difficult to estimate because much abuse goes unreported. Bullying and favoritism by staff are also found in many institutions. Other aspects of the prison environment that can be sources of stress are noise levels, lack of control over lighting, physical discomfort arising from extremes of heat and cold, lack of contact with the natural environment, absence of intellectual stimulation, and constraints on physical activity. One issue that is problematic is the pressure not to show evidence of distress. Often emotions associated with stress such as fear, grief, and depression are not admitted and are hidden from staff and other inmates. This hinders the analysis and solution of stress-related problems. Time Course of Imprisonment
Certain sources of stress are more evident at different stages of imprisonment. Three phases of a prisoner’s career have been identified. Initial phase This is the most stressful period when the inmate first encounters prison life. First-time
Prison 219
offenders are particularly vulnerable due to the loss of liberty and separation from friends and family. This stage is often characterized by feelings of denial followed by anxiety and depression, although other emotions such as shock, fear, isolation, grief, and anger are also reported frequently. The adjustment period typically lasts for the first 4–6 weeks of confinement. It is at this stage that many suicide attempts are made. Middle phase During the middle stage of the sentence, the focus is on the prison community. Friendships are established, and some inmates experiment with drugs and gay sex. Mandatory drug testing has been introduced in many countries; despite efforts to prevent the importation and use of illegal drugs into prisons, the problem is common. In 2001, a UK prison survey found that 19% of inmates reported using cannabis in the previous month, and 13% reported using opiates. Although drug use is prevalent, a smaller proportion of inmates use drugs while in prison than did prior to incarceration. Final phase Some convicts become preoccupied with their release in the final few weeks of their prison terms. Apprehension about cultural changes after long sentences is coupled with worry about the attitudes of friends and neighbors and the need to reestablish family relationships and reenter employment. Health and economic disparities that existed before incarceration are intensified following release, because access to jobs, health insurance, public housing and health benefits may be limited to exprisoners, particularly in the United States, and disproportionately in ethnic minority groups. Thus incarceration continues to exert effects leading to increased stress and poor health even after release. Responses to the Stress of Prison Life
The stress experienced by prisoners has been measured in several ways: by self-report measures of mood, well-being, and mental health; by the incidence and prevalence of physical health outcomes, mental health outcomes, and physiological indicators of stress; and by the most powerful indicator of hopelessness and despair, suicide. The investigation of the psychological state of inmates and stress-related effects in prisons faces a number of methodological challenges. First, assessing the impact of incarceration is complicated by limited knowledge about the prior health and well-being of inmates. Many studies of stress in prisons that use outcomes such as hospitalization for mental illness
during incarceration are problematic in that incident psychopathology, that is, new onset mental illness, may be difficult to distinguish from prevalent psychopathology, which has been consistently demonstrated as having higher rates in prisoners. Longitudinal studies following prisoners from the first days of incarceration are the only way of studying the emergence of stress resulting from the prison environment rather than ongoing stress from psychosocial disadvantage or existing psychopathology that entails greater risk of conviction in the first place. Second, the general population is a poor comparison group when assessing the relative prevalence of stress-related disorder in prisoners. Many individuals sent to prison have histories of psychological problems and drug abuse prior to sentencing. Inmates also tend to come from low-income families, to be unemployed, and to have limited education and therefore may have previously encountered negative life events, inadequate health care, and poor living conditions. Drug and alcohol problems frequently precede incarceration; a survey of convicts in state prisons in the United States indicated that 50% of those convicted of violent crimes were under the influence of drugs or alcohol at the time of the offense, and in 1993 drug offenders accounted for 61% of inmates in federal prisons. The high prevalence of some problems among inmates cannot, therefore, be attributed to the prison experience and is confounded by considerable preexisting psychosocial disadvantage in this group. Nevertheless, anxiety, depression, and complaints of fatigue, sleeplessness, headache, and backache are common. In one study of female convicts, nearly half met the diagnostic criteria for posttraumatic stress disorder (PTSD), and major depression was more prevalent than in the general population. A study of a representative sample of imprisoned juvenile delinquents in California found that half experienced PTSD, with many having witnessed or been involved in traumatic violent episodes. The prevalence of infectious disease, sexually transmitted disease, and tuberculosis is also high compared with the general population. Substantial weight gain has been recorded among female inmates, resulting from the combination of the sedentary lifestyle and the availability of energy-dense high-fat foods. A recent British study investigating subjective health status in female inmates addressed the confounding by lower socioeconomic status in prisoners. Using a comparison group of women from lower-socioeconomic-status sectors of the community, a comparable level of physical health complaints and a greater level of mental health complaints were found in prisoners.
220 Prison
Blood pressure has been found to be elevated in prison inmates compared with matched controls and to increase with the duration of confinement and the degree of crowding in prison. One particularly impressive study used a quasi-experimental approach by measuring the blood pressure of male convicts assigned to individual cells, four-bed cells, and larger dormitories in a medium-security prison. Blood pressure increased to a greater extent in men who were transferred to multiple-occupancy cells and dormitories compared with those who were transferred to other individual cells. However, a third methodological problem with studies of physiological stress markers is that prison studies have not kept pace with recent advances in measuring such markers as ambulatory blood pressure, cortisol, catecholamines, and inflammation. One notable exception is the Copenhagen Solitary Confinement study, which assessed changes in mood, orientation, and serum cortisol during the first 3 months and compared prisoners kept in solitary confinement (SC) with prisoners in shared cells. Although anxiety, depression, and morning cortisol levels were reduced over time in the non-SC group, such reductions did not occur in the SC group, indicating a lack of adaptation to the prison environment. Many physiological markers of stress are good prognostic indicators of health problems such as autoimmune and cardiovascular diseases, and therefore it may be fruitful to pursue this avenue. International surveys have found that the suicide rate in prison is between 3 and 11 times greater than that of the general population, with a reported fivefold increase compared with the UK general male population from 1978 to 2003. Most suicides take place within the first few weeks of incarceration and are more common in crowded institutions than other prisons. High rates have been recorded among prisoners on remand and those convicted of murder and serving life sentences. Although suicide is most frequent in young males, self-harm is highly prevalent in female inmates, and recent UK Home Office statistics report a rate of 58.7%. Unlike the pattern in the general population, depression is not a common diagnosis at the time of death, although about onethird of male suicides had some form of psychiatric treatment in the past. Drug or alcohol dependence can be found in a substantial proportion of these cases. There is also evidence for a European trend toward reinstitutionalization of those with mental health problems in recent years – but in prisons rather than in psychiatric hospitals. A systematic review of prevalence studies in Western countries in 2002 found an overall prevalence of 3.7% for psychotic disorders (10% for major depression), representing a two- to
fourfold increase in mental illness compared with the general population. It is likely that U.S. prisons and jails hold up to twice as many individuals with mental illness than do state psychiatric hospitals; the prison system is not well equipped to support these individuals. Characteristics of the Individual Convict
Some individuals adapt to incarceration better than others and survive even lengthy prison terms without experiencing high levels of distress. Older convicts tend to have more friends in prison, to have more contact with family and friends outside, and to report greater psychological well-being than younger individuals. A recent UK Home Office report, however, drew attention to the often overlooked but growing population of prisoners aged 60 and over. Although physical health problems in this cohort are often well provided for, psychiatric problems, in particular major depression, are not well treated. Political demand for longer sentencing for some crimes means that this older cohort will continue to provide an ongoing challenge for prison services. As noted earlier, higher levels of anxiety and depression are found in female than in male prisoners, although it is not clear whether this is a specific response to imprisonment or reflects the more general difference in distress found in the adult population at large. Members of ethnic and religious minorities suffer more than members of the majority because prejudice and cultural isolation are added to the other sources of stress present in prison. In the United States, it has been noted that White prisoners are more likely to attempt and complete suicide than African American prisoners, but the reasons are poorly understood. One suggestion is that being raised in the tough conditions experienced by many African Americans makes adults more resilient to the pressures of prison life. Alternatively, because proportionately more Black than White Americans are incarcerated, they may come from a broader spectrum of society; White inmates may include a higher proportion of marginalized, psychologically vulnerable individuals. Methods of Reducing Stress among Inmates
The management of stress in prison inmates involves several different levels of intervention. Medical and psychiatric services have an important role in preventing suicide and self-harm, in managing drug dependence, and in treating other psychiatric and neurological problems. Support is often hampered by the reluctance of inmates to divulge personal information to authorities or to reveal weakness. Training prison staff more generally in suicide prevention
Prison 221
is also important. A recent public health initiative in Texas prisons led to improvements in health outcomes, and Telemedicine, allowing rapid access to telephone consultations for physical and mental health problems, proved to be a novel and effective way of delivering health care. At a more general level, education, training, and other initiatives help build prisoners’ self-esteem and confidence in their ability to adapt to civilian life after release. Increasing physical activity and exercise may also be beneficial. Studies have found that inmates who have a job detail or are on work-release programs show less evidence of stress than those who are not active. Finally, changes at the institutional level may be warranted. It is likely that modifications of prison regimes in relation to aspects such as staff attitudes, privileges, training opportunities, and relocation of inmates to serve their terms near their families could play a key role in alleviating stress among inmates. However, the reality is that stress does not figure highly among the concerns of prison administrators or politicians, some of whom would argue that prison should be stressful.
Prison Staff
United States, where ethnic minorities are grossly overrepresented among inmates. Some differences have been observed between new and long-serving staff. Newly appointed staff members report a lack of support from supervisors and a concern with lack of control over the working environment as particularly problematic. Those who have been working for longer periods are more troubled by the absence of support and respect from society and the lack of variation in the job. The combination of tedium associated with mundane day-to-day activities and the pressure to maintain vigilance in order to react quickly to high-risk incidents appears to be especially stressful. Many prison officers believe that the responsibilities for security and the welfare of inmates are incompatible obligations. A recent meta-analysis of factors predicting work-related stress revealed an interesting effect of punitive versus rehabilitative attitudes – officers in the United States who endorsed rehabilitative attitudes experienced greater stress, whereas those in Canada with stronger punitive attitudes were more stressed. This suggests that when individuals’ beliefs about their role are at odds with the ethos of the prison service in a particular country, stress and conflict are the result.
Sources of Stress
Research on prison staff members finds that many of the issues cited in the general literature on occupational stress are relevant for them as well. As with other jobs, factors such as work demands, role conflict, low control, and poor social support emerge as relevant. Thus, symptoms of psychological distress and job dissatisfaction are greater among correctional officers who report high work demands coupled with low control and low support from management and colleagues. However, these problems are exacerbated by the peculiar requirements of working in prison. Prison officers cite the conflict of responsibilities in the job as an underlying source of stress and dissatisfaction. On the one hand, prison staff members are responsible for the welfare of inmates and for the maintenance of their physical and psychological well-being. On the other hand, they are required to maintain security and protect the public from the dangerous and sometimes violent convicts. The prison environment is often volatile, with a high risk of aggressive behavior from inmates. Confrontations with inmates and the threat of physical danger are cited as major sources of stress, irrespective of the age and gender of staff members. Ethnic minority prison officers have been found to experience lower stress levels, especially in the
Outcomes of Stress
High rates of sick leave for both minor complaints (fatigue, headaches, and indigestion) and physical health problems (high blood pressure and peptic ulcers) occur among prison staff. In one study, the rates of coronary heart disease, hypertension, and ulcers were found to be greater among correctional officers than a comparable sample of police officers. The divorce rate in correctional officers is reported as being twice that of blue- and white-collar workers in general. Job dissatisfaction is coupled with the increased prevalence of divorce in this occupational group. The rates of sick leave are greater among staff members in maximum security prisons and in prisons with many drug users than in other correctional institutions. There is a greater prevalence of psychological distress in prison officers. Much of the research has focused on burnout, with male and female staff members reporting similar high levels of depersonalization and emotional exhaustion. Self-reported anxiety and depression are also elevated compared with the general working population. Female officers are more likely to take sick leave than male officers, but this pattern may result from family demands rather than different levels of stress at work.
222 Prison Methods of Reducing Stress in Prison Staff
It has been noted in the research literature that many prison officers do not perceive themselves to be stressed but, rather, see their colleagues as being stressed. Pressure not to show the effects of stress may be particularly evident in a male-dominated environment where there is fear that any sign of weakness will be exploited by the inmates. Admitting to feeling stressed may be interpreted as an inability to cope and therefore as not being strong enough for the job at hand. Alternatively, some prison officers may not be able to identify the personal effects of stress in themselves. This suggests that education about stress and how it can be managed may both benefit prison staff members directly and help them to identify the repercussions of stress in inmates. A number of studies have found that exercise and fitness programs have positive effects. One investigation involving a 6-week strength and aerobic program showed reductions in body weight, skinfold thickness, and cholesterol levels, together with beneficial changes in smoking, alcohol consumption, sleep, nutritional habits, and stress tolerance. Consultation and efforts to enhance social support at work have been found to counteract the effects of stress. Factors such as goal consensus among staff, a proactive management style, and increasing of decision latitude can be incorporated into the working environment.
Limitations and Conclusion There are a number of limitations in the studies that have been carried out thus far about stress in prisons. Most have been cross-sectional in nature, identifying associations between aspects of prison experience and diminished well-being, and the causal sequence is uncertain. Longitudinal designs and data on inmates prior to imprisonment are important in the assessment of the impact of stressors because some apparent effects of incarceration may be the direct consequences of prior experience. The nature of the offense, family situation, and previous physical and mental health are all important factors that should be taken into account. Also, the civilian groups with which prisoners are compared in many studies may not be matched appropriately in terms of background characteristics. The generalizability of results across populations is uncertain. The majority of studies have been conducted on White male adults and may not be relevant to women, ethnic minorities, and juveniles. This is
not mere tokenism because it is apparent from the limited information available that the experience of prison is very different for people of different backgrounds and cultures. The applicability of findings to different prison systems must also be questioned. Justice systems in the United Kingdom and other European countries differ greatly from the U.S. system, and countries also vary in the extent to which individuals with serious psychiatric histories are found in prison. The application of management suggestions derived from one system must be reviewed carefully before their implementation elsewhere. Nevertheless, the data do indicate that imprisonment is severely stressful for many inmates and that work within the prison system is also associated with higher rates of stress-related dysfunction than comparable jobs. Education and the implementation of specific stress-management programs may be beneficial to both groups and may help ensure that stress in prison is confined within tolerable limits.
See Also the Following Articles Burnout; Crowding Stress; Prisoners of War; Racial Harassment/Discrimination; Workplace Stress.
Further Reading Andersen, H. S. (2004). Mental health in prison populations: a review. Acta Psychiatrica Scandinavica 110(supplement 424), 5–59. Andersen, H. S., Sestoft, D., Lillebaek, T., et al. (2003). A longitudinal study of prisoners on remand: repeated measures of psychopathology in the initial phase of solitary versus nonsolitary confinement. International Journal of Law and Psychiatry 26, 165–177. Cooke, D. J., Baldwin, P. J. and Howison, J. (1993). Psychology in prisons. London: Routledge. DeRosia, V. R. (1998). Living inside prison walls: adjustment behavior. Westport, CT: Praeger. Hayes, L. M. and Blaauw, E. (eds.) (1997). Special issue on prison suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention 18(4). Dowden, C. and Tellier, C. (2004). Predicting work-related stress in correctional officers: a meta-analysis. Journal of Criminal Justice 32, 31–47. Lindquist, C. H. and Linquist, C. A. (1997). Gender differences in distress: mental health consequences of environmental stress among jail inmates. Behavioral Sciences & the Law 15, 503–523. Ostfeld, A. M., Kasl, S. V., D’Atri, D. A. and Fitzgerald, E. F. (1987). Stress, crowding and blood pressure in prison. Hillsdale, NJ: Lawrence Erlbaum. Paulus, P. B. (1988). Prison crowding: a psychological perspective. New York: Springer-Verlag.