“Fear can hold you, hope can set you free”. Analysis of Italian prisoner narrative experience of the COVID-19 pandemic

Introduction

Since the end of February 2020, Italy (especially the Lombardy region) has witnessed the rapid spread of COVID-19. Afterwards, on 11 March, the World Health Organization (WHO) declared it a pandemic. On 8 March 2020, the Civil Protection Department in Lombardy declared the presence of 3,372 positive cases of COVID-19, an increase of 630 compared to the previous day. A total of 267 people had died (a further increase of 113) with 4,189 total cases (an increase of 769) (Protezione Civile, 2020). On the same day, total cases in Italy were 7,243, which at the time accounted for almost 60% of the total cases in Europe (12,226) and 23% of the cases worldwide (31,303) (ECDC, 2020).

Following the rapid increase of COVID-19 infections, the Italian Government promptly intervened with preventive and containment measures throughout the country, including prisons. The preventive and containment measures applied in prison (described below) were taken before the publication of Europe’s Regional WHO Office’s guidance: “preparedness, prevention and control of COVID-19 in prisons and other places of detention”, published on 15 March 2020 (WHO, 2020).

The urgency in adopting preventive and restrictive measures was related to the closed nature of the prison setting which increases the risk of infections. Pathogens like COVID-19, transmitted from person to person via droplets or close contact, are extremely likely to spread rapidly in prison – due to environmental factors such as overcrowding, poor ventilation, close habitation or dormitory-style housing and poor hygienic conditions (Montoya-Barthelemy et al., 2020; Dutheil et al., 2020; Dolan et al., 2016). Furthermore, the underlying health conditions of people in prison (e.g. chronic diseases and mental health illnesses) make them more susceptible to contracting severe infectious diseases (Wurcel et al., 2020; Crowley et al., 2018; Fazel and Baillargeon, 2011).

For these reasons, anti-contamination measures must be strongly adhered to in prisons (Kinner et al., 2020). On 26 February 2020, the Head of the Italian Department of Prison Administration launched widespread awareness and information-raising activities concerning the virus. In addition to the instructions already provided by the Ministry of Health (i.e. use of protective equipment, disinfection procedures and physical distancing) the Department of Prison Administration chose to adopt the following restrictive measures (Ministero della Giustizia, 2020):

• suspension of release on temporary licence and semi-freedom regime;

• suspension of group treatments;

• suspension of activities for which external community access is foreseen or necessary;

• containment of external and internal work activities for which the presence of people from outside is foreseen; and

• replacement of visits with family members or third parties with remote correspondence calls using the equipment provided in prison (Skype) and telephone.

Time allowed outside the cells was also significantly reduced to limit contact between people in prison as much as possible.

On 7 March 2020, the Lombardy region declared lockdown (i.e. an emergency protocol that included the order to stay at home, closure of public spaces, schools and most workplaces). It was followed by a nationwide lockdown two days later, indicating a worsening situation. People in Italy could only move around for grocery shopping, doctor’s visits or going to work. A self-certification form was required by all detailing the reason for movement and travelling within or outside of the city was prohibited.

Following the declaration of the lockdown, the Italian penitentiary system was heavily shaken by serious riots (Buffa, 2020; Cingolani et al., 2020). The violent riots originally broke out in Lombardy and spread to 22 prisons all over Italy including Foggia, Modena, Rome Rebibbia, Rome Regina Coeli, Bologna, Melfi, Rieti, Bari, Palermo, Santa Maria Capua Vetere, Velletri, Prato, Milan San Vittore, Matera, Chieti, Ivrea, Caltanissetta, Enna, La Spezia, Ferrara, Termini Imerese, Trani and Potenza between 7 and 9 March 2020. These riots involved roughly 6,000 prisoners and caused considerable damage to prison facilities and injuring dozens of people including 40 prison officers. It was observed that 12 prisoners died from overdoses of psychotropic drugs and methadone stolen from prison pharmacies during the riots [1] [2]. The riots were in response to the implementation of restrictive measures, which included the interruption of external visits, uncertainty and fear of the situation.

San Vittore, which is in the heart of Milan, is the largest correctional facility in Lombardy. It was the site of one of the most violent riots that broke out at the beginning of March 2020. It hosts mainly people on pre-trial detention and has a capacity of 799 with a section for men and another for women prisoners. The prison has a star-shaped structure with six wings that correspond to the six sections of the prison. At the time of the COVID-19 outbreak in Lombardy, San Vittore housed about 1,029 people in prison (931 men and 98 women) with an overcrowding rate of 129% (Ministero della Giustizia, 2020b).

San Vittore represented an important site during the lockdown. Following the first positive cases in prison at the end of March, “DOCTORS WITHOUT BORDERS” in collaboration with the management of San Vittore, set up a centre for the treatment of COVID-19 within the prison, becoming the reference hub in Lombardy for the management of prisoners testing positive. COVID-19 positive people from other prisons were transferred to San Vittore to be placed under observation and monitored. The San Vittore initiative was later extended to other prisons in Lombardy, Marche, Piedmont and Liguria [3].

Currently, there is little research on the effect of the COVID-19 pandemic on prisoners (Carvalho et al., 2020). To date, studies have focused mainly on the effects of isolation and quarantine (i.e. the separation and restriction of movement of people who have potentially been exposed to a contagious disease) among the general population (Brooks et al., 2020; Loades et al., 2020; Chtourou et al., 2020; Clemente-Suárez et al., 2020). A review on the psychological impact of quarantine among the general population highlighted that separation from loved ones, inadequate information and supplies, the loss of freedom, uncertainty over disease status, fears of infection and boredom are predictors of psychological distress and disorder (Brooks et al., 2020).

The addition of such factors to those already deprived of their liberty (i.e. prisoners) further increases their psychological and behavioural reactions compared to people in the community (WHO, 2020). Suspension of visits (including volunteers, members of charities, trainees, students, etc.) reduces contact with the outside world and might produce the use of maladaptive coping strategies due to the perception of poor social support (Hewson et al., 2020b).

During the months of lockdown, people in the community have engaged in creative activities to avoid succumbing to boredom and lack of contact with other people. Much use has been made of the internet, smartphones and social networks. However, substitute activities are scarce in prisons, where access to the internet is restricted. The scarcity of activities, increased time spent in cells (about 23 h/day) and little or no contact with other people and the outside world, mimic conditions of solitary confinement. Even short periods in solitary confinement are associated with psychological consequences, including anger, depression, anxiety, paranoia, psychosis and exacerbation of underlying mental illness (Hewson et al., 2020; Shalev and Edgar, 2015). Liebrenz et al. (2020) highlight that due to the high prevalence of mental and physical illness (Fazel and Seewald, 2012) and drug addiction among people in prisons (EMCDDA, 2019), putting them in quarantine and depriving them of visits from their psychiatrists and families can worsen the situation.

If quarantine or isolation is essential, then it is equally important to take every measure to ensure that this experience is as tolerable as possible for people (Brooks et al., 2020). This can be achieved by providing knowledge about what is happening and why, providing meaningful activities, ensuring supplies such as masks, disinfectants and regular sanitizing materials (especially in a context of prison overcrowding) and continuing to provide psychiatric and psychological support. Recent studies underlined the difference in the development of psychological distress between quarantined people in prison and the general population (Kothari et al., 2020; Okoro et al., 2020). Okoro et al. (2020) observed that the high level of psychological distress among people in prison can stem from a poorer level of knowledge about COVID-19, sometimes associated with lower levels of education compared to the general population.

Starting from these considerations, the current study focuses on the psychological consequences of the COVID-19 lockdown among prisoners in a Lombardic prison, with an assumption that the situation may have contributed to greater psychological distress.

Given the impossibility of entering prison, the authors chose to focus on the qualitative content analysis (CA) of posts written by the people in San Vittore Prison (Milan, Italy) posted on their institutional blog “L’Oblò” (“The Porthole”) during the early stage of the COVID-19 pandemic in Italy. By analysing blog post content, it was possible to gain a thorough understanding of prisoner experiences without conducting interviews.

Method

Results

According to the inclusion criteria, 27 out of 35 posts published on the blog during the established period were included. Posts were written by 17 separate individuals and varied in length from 98 to 484 words (M = 200, 4; SD = 101, 848). Nine posts were excluded due to the following reasons:

• articles did not relate to COVID-19;

• articles were written by professionals; and

• articles did not have the first-person experience of the prisoner during the lockdown as their main subject.

CA of the posts allowed us to describe the psychological conditions of people living in a Lombardy prison during the early phase of the COVID-19 pandemic. The content of the 27 posts included in this study has been divided into two major categories based on how people chose to write about their experience, i.e. from a more cognitive or emotional perspective.

The CA showed that “emotional connotations” (n = 94) were more common than “cognitions” (n = 79), and that emotional connotations were more likely to be negative (65/94) than positive (29/94). The most frequent negative emotional connotations were: missing, worry, psychological pain and fear, whilst the most frequent positive emotional connotations were hope and gratitude for the support received from prison workers. The most frequent cognitions were: descriptions of the lockdown effects on detention, descriptions of the prison during the COVID-19 emergency, the commitment of people in prison, evaluations of the virus and the riots, requests to the institutions (e.g. the Italian Minister of Justice).

A complete list of topics and subtopics for both cognitions and emotional connotations are provided, respectively, in Tables 1 and 2.

Requests to institutions

The least frequent topic (6%, 5/79) categorized under cognitions was represented by explicit “requests to the institutions”. The term “institutions” not only includes institutional bodies in general but also the Ministry of Justice and the current Italian Minister of Justice. Such requests included asking the institutions to consider granting people in prison extraordinary measures in terms of finalizing their sentences given the emergency:

I would expect the Justice Department to carefully consider the possibility of a pardon or, indeed, of house arrest before the virus prevails even in prison or other riots break out. (ID 14, 46 y/o)

We appeal to the penal institution to understand the suffering of being shut away almost 24 hours a day in cells of 3 by 4 meters, distressed by what is happening to our loved ones. (ID 6, 56 y/o)

Emotional connotations

Participants wrote about emotional connotations 94 times in their 27 blog posts, making it more frequent than “cognitions” (n = 79). Emotional connotations were divided into positive and negative. Despite a good percentage of positive emotional connotations (31%), most of the emotional connotations expressed were negative (69%). All subtopics associated with positive and negative emotional connotations are presented below.

Discussion

In the current study, the experience of 17 prisoners living in a Lombardy prison during the COVID-19 pandemic was explored using the qualitative CA of 27 narratives posted on “L’Oblò”, the institutional blog of “La Nave” ward in San Vittore prison (Milan, Italy).

Previous research highlights how narratives can help people cope with a stressful experience (Saita and Acquati, 2020) and can help researchers understand how people live life experiences (McAdams, 2012). Narratives have been used in the forensic field and are considered effective in prison populations because they allow prisoners access to the world, and therefore, provide them with a sense of stability and unity (Saita, 2018). In this case, the CA of narratives could be used to help prison administrations and policymakers better understand situations of crisis and develop more effective solutions and programs that address the issues and needs of prisoners. The current research led to the identification of two dominant categories of themes addressed in participants’ posts: cognitions and emotional connotations linked to the COVID-19 experience in prison.

Contents expressing the individual percepts, thoughts, ideas, opinions and explanations, related to the COVID-19 pandemic were assigned to “cognitions”. Cognitions have been defined by Neisser (1967) as all processes by which sensory input is transformed, reduced, elaborated, stored, recovered and used. Cognitions involve perceiving, conceiving, remembering, reasoning, judging, imagining, problem-solving (APA, 2020). According to Jackson and Crosson (2006) by “emotional connotations”, we mean the emotional property of an object, action or event. It is not a direct reference to an emotion such as happiness, sadness, anger or fear. It is implied knowledge that an object, action or event is likely to evoke a specific emotion. In our case, the event that produced emotions is the COVID-19 pandemic.

Cognitions were divided into four topics: descriptions, evaluations, commitment and requests to institutions, whilst emotional connotations were divided into positive and negative. The 27 blog posts written by the participants are mainly characterized by negative emotional connotations related to the experience of the COVID-19 pandemic in prison. Nevertheless, there are aspects in both cognitions and emotional connotations that are worth discussing in more detail.

Although, as expected, most of the participants’ cognitions were concentrated on the description and evaluation of the pandemic in prison, they also demonstrated a certain degree of commitment to dealing with the situation. In total, 15 out of 27 posts displayed how those in prison tried to be hopeful and positive, despite the distressing situation they were living in as one of the most vulnerable population groups. As pointed out by the WHO (2020), people in prisons typically have a greater underlying burden of disease and detrimental health conditions than the general population. They frequently face greater exposure to risks such as smoking, poor hygiene and weak immune defence due to stress, poor nutrition or prevalence of coexisting diseases, such as bloodborne viruses, tuberculosis and drug use disorders (Coninx et al., 1995; Macalino et al., 2004).

Despite all these difficulties, the participant’s positive attitudes could be related to the availability of information about the virus that they received. Although two participants evaluated information as “insufficient”, is it known that since the beginning of February, the Penitentiary Health Systems of Milan launched an information campaign in local prisons concerning the ongoing health emergency. In San Vittore, infectious diseases specialists with the help of nurses and prison officers have been meeting prisoners, ward by ward, offering explanations and carrying out awareness-raising activities, which have often been consolidated with the involvement of certain prisoners. In addition, leaflets have been distributed and placed in different languages throughout all wings. Workers of “La Nave” ward have confirmed that an awareness-raising campaign on flu and anti-pneumococcal vaccination is currently underway. It is well known that receiving information about COVID-19 could prevent psychological distress or anxiety (WHO, 2020), whilst a paucity of information can produce high psychological distress for prisoners (Okoro et al., 2020). For “cognitions” an interesting issue was the way detainees evaluated and represented the virus to themselves. It is easy to imagine how something unknown like COVID-19 could be represented in a distorted or exaggerated way (Büchi et al., 1998; Tosoli et al., 2011). Participants defined it as “an ‘inhuman killer”, “created by humans” and an “evil which causes victims”, whilst some attributed confused and unrealistic qualities to the virus. Often, a negative image of the virus was linked to a more anxious outlook.

Other important aspects to be discussed can be found within the category “emotional connotations”. Even though negative emotional connotations were more frequent, among the positive ones there were messages of hope and gratitude for the support given by the prison workers. Our sample is entirely constituted by people struggling with substance use disorder and who follow a special treatment program, as members of “La Nave” ward. Unlike other wards of San Vittore, their treatment activities had not been completely suspended. As pointed out by the participants, group activities were interrupted due to social distancing, but individual sessions continued to provide psychological support. This is in line with recommendations not to interrupt any psychological support to the prison population even during a world health emergency (Liebrenz et al., 2020).

Despite these efforts, several negative emotional connotations were felt by participants during the lockdown. The most frequent were missing, anxiety, psychological pain and fear. Missing was expressed by participants not only towards their family members due to the suspension of the visits but also towards their previous habits in the prison. Missing their daily routine was often felt, accompanied by psychological pain and disorientation to underline the difficulty of adaptation.

As highlighted by literature, isolation and a reduction in social interactions are dangerous for a person’s mental health and confinement in a cell for many hours a day with very few social contacts (as during the pandemic) can cause strong emotional disturbances (Haney, 2018). Psychological reactions due to isolation are, for example, stress-related reactions, high levels of anxiety, confusion, loss of emotional control and mood swings (Smith, 2006; Arrigo and Bullock, 2008).

Similar consequences have been found in the posts written by the individuals of our sample. Texts report emotions such as anxiety, confusion, difficulty in expressing one’s emotions in words, mood instability, struggling to stay rational, fear and anger. These emotions appear plausible considering, for example, that social distancing to reduce the risk of contagion is not feasible in prisons because people are confined to small living spaces and institutions are often over capacity (Wurcel et al., 2020; Dumont et al., 2012; Marushak et al., 2009).

It is well known that the need and importance of psychological interventions in prisons are beneficial in many ways. People who do not receive psychological treatment have a major risk of recidivism after release (Mears and Cochran, 2012; Baillargeon et al., 2009); psychological health improves in those who have followed group therapy (Khodayarifard et al., 2010); psychopathological symptoms have been shown to decrease after prisoners have received psychological support (Shelton et al., 2009).

Despite the gratitude expressed for the attention and support delivered by prison workers, participants pointed out discontent concerning suspended activities (especially the group ones). The interruption of treatment activities and visits from families could have a negative psychological impact on the precarious emotional balance of this fragile population already deprived of freedom. Consequences could be devastating as demonstrated in Italian prisons (including San Vittore), where violent riots occurred following the tightening of contagion risk containment measures.

It was not the aim of the current study to analyse the reasons for the riots; however, several negative connotations in the posts led us to presume that the changes enforced by the pandemic generated negative consequences. Even if adjustments are necessary, often they are applied without full consideration of the habits that characterize the context (Saita, 2018). Semenza and Grosholz (2019) observed that those in prison dealing with concurrent mental and physical health troubles have a higher probability to engage in misconduct than healthy individuals. We can suppose that the COVID-19 related negative emotional connotations, expressed by the people living in San Vittore, was likely to lead to violence.

Given the deprived conditions and its specific clinical features, the prison population are perhaps prone to develop psychological distress because of an event that we can define as catastrophic. However, the analysis of the participants’ narratives, written during the COVID-19 pandemic, confirmed:

• how important information on what is happening is and the overall importance of communication;

• that continuity of psychological support provided by the professionals (although compromised by anti-contagion standards) should be considered as an important protective factor that allowed detainees to voice their feelings and professionals to understand and treat the participants’ emotional states.

Limitations

The current study presents several limitations. One is represented by the small number of participants and posts that form the basis of the analysis. Moreover, we included posts collected from only one blog. The rationale behind the use of “L’Oblò” is that it is the only blog updated from both prisoners and prison workers of a prison within the Lombardy region (i.e. the Italian region most affected by the COVID-19 pandemic). Beyond that, the experience narrated by the participants is unique because of the particularity of the ward where they are hosted. At “La Nave”, special attention is given to the psychological treatment of people with substance use disorder.

Even though every one of the wards is free to participate in writing on the blog, without incurring any consequences, the sample comprises a selected number of individuals. It is limited to those people who choose to participate in writing on the blog and who can write well enough in Italian. Moreover, the analyses were conducted on posts published during a specific period, corresponding to the initial phases of the pandemic in Italy. Over time, things might have changed because of progressive adaptation to the situation.

Implications

Despite the limitations listed above, this study made it possible to raise awareness about a low-cost and easy-to-use tool/means (i.e. the blog) that can help people in prisons to record their experiences and to make their voices heard. At the same time, the study highlights the need to think about and provide this population with more opportunities for self-expression, which will help to shorten the distance between inside and outside the prison.

In this case, better understanding the experiences of people living in an Italian prison during the COVID-19 pandemic allows us to consider information that can lead to improvements for future experiences in the detention context. Indeed, there is a need to coordinate both the health and the justice services for supporting people in prison during a pandemic. Moreover, prison health-care staff must monitor the needs of people in prisons and try to respond practically or communicate better to prevent riots and violence. As mental health services in the community played and still play an essential role in helping their patients during this pandemic, it is equally important to enhance mental care for the most vulnerable. In fact, despite the negative feelings that the experience of the pandemic has caused, being located in a prison ward with a higher level of attention (because of the drug addiction treatment program) allowed our participants to experience a positive attitude.

The psychological experience of positive elements such as hope can be a protective factor in emergencies (Demetriou et al., 2020). Among our sample, hope seems to have been encouraged both by the psychological support that prison workers have continued to provide (despite the limitations) and the information and awareness campaign on the virus promoted by the Milan Prison Health System. Our results support a clear need for additional psychological support for people in prison, promoted at an individual level and, if necessary, with alternative provisions such as the telephone or computer when confronted with a reduction in staff.

Resources invested in this way could reduce the negative impact of a catastrophic event on the already impaired health of this fragile population. Underestimating the importance of these choices can expose judicial systems to serious consequences such as those that occurred in Italy.

Finally, this study provides useful information that contributes to the literature by discussing the psychological effects of a world health emergency such as the COVID-19 pandemic among those in prison. Through blog posts, it has been possible to analyse the subjective experience of a population often ignored or considered unworthy of being heard.