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the Sunday essay...There is no help for prisoners withmental health problems. Prisondi d n’t fix my mental health issuesand did nothing to help themJulian (peer researcher)

S ociety has a tricky relationshipwith men and women who haveserved their prison sentences

and been released.On the whole society is content

with the notion of ‘do the crime: servethe time’, but what happens whenthat time is served and the individualis released back into the com-munity?

Do we welcome or exclude? Are wesatisfied that a lesson has beenlearned, or are we concerned that theindividual will re-offend? Do we wantto understand the problems they faceon release, or would we rather brushthose issues under the carpet?

The story of a former prisoner isabout more than the offence or of-fences they have committed, and thepunishment that has been meted outto them as a result.

Many come with difficult backstories that begin in childhood: ofneglect; abuse; an unstable familylife; experience of poverty or need; alack of engagement in education; thesense of being failed by society.

According to Ministry of Justice,statistics published in July 2013, al-most a quarter of all prisoners (of aprison population of more than85,000) had lived with foster parentsor in an institution, or had been takeninto care at some point as children.

More than 40 per cent had seenviolence in the home as a child, andalmost two-thirds had at some pointbeen temporarily excluded fromschool – more than 40 per cent hadbeen permanently excluded.

It is probably too simplistic a cor-relation to link such difficulties inchildhood with a propensity to of-

fend, or to an increased risk of mentalhealth problems, but the cause isclear, even if it does not hold for all.

Little wonder then that the lastOffice of National Statistics survey tocover the issue showed that 64 percent of male sentenced prisoners, and78 per cent of men in remand, had apersonality disorder.

Other problems such as depressionand anxiety, were also comparativelyhigh: 40 per cent in male sentencedprisoners and 55 per cent in males onremand. For women the figures werehigher still: 63 per cent and 76 percent respectively.

Prisoners have a high prevalence ofmental health problems. Rates forvarious mental health conditions as awhole, range from 50 to 90 per cent.Prisoners released from prison withmental health problems face diffi-culty with family relationships, em-ployment, long-term illness, depres-sion, self-harm and re-offending.

And re-offending is an issue. Thosemost likely to re-offend are prisonerswho have received sentences of oneyear or less – nearly 60 per cent ofthose leaving prison. Such individu-als are so-called ‘revo l ve r s ’ or ‘chur n-ers’ – frequently in and out of prison.Their lives revolve between chaoticexistences in the community andspells in custody. As such, often theyare not under the supervision of pro-bation services, neither do they havemeaningful contact with primarycare or specialist mental health ser-vices before or after release.

It is this group which is most atrisk of re-offending and of causingthemselves harm. The age-adjustedrisk of suicide for male offendersleaving prison is eight times the na-tional average, and over a quarter offatal suicide attempts happen withinfour weeks of release. Almost aquarter of all deaths under ProbationService supervision are cataloguedas suicides, often by violent means.My first research related to offenders

Key to ensuring the work of Plymouth University Pen-insula Schools of Medicine and Dentistry is effective andrelevant has been the input from men who have beenthrough the prison system, so-called ‘peer researchers’.Two such peer researchers are Steve and Julian.

Julian had a sad event in his life. In order to help ease hisgrief Julian turned to drugs, and shoplifted to help fund hisneed. He was sentenced three years ago for shoplifting.

He said: “There is no help for prisoners with mentalhealth problems. Prison didn’t fix my mental health issuesand did nothing to help them. That’s why I’m involved in thisproject – there needs to be a better understanding of whereand how people can get help. There needs to be bettersharing of information between prisons and outside agen-cies – no more ‘out the door and see you later’. We needplaces where we feel safe. Doing this makes you feel good.”

Steve was sentenced in 2009 for supplying heroin. Duringhis time in prison he received one half-day session onrelapse prevention and no help for addressing the emo-tional issues that led to his conviction.

He said: “When you are released with a mental healthproblem there are well-meaning agencies which are un-fortunately ill-suited to helping people, and services suchas probation are hard to be open and honest with – it is tooeasy to fall through the system. By being involved with thisproject we can make a positive contribution to how peoplelike us are supported in the future. People aren’t in-herently bad and there are factors behind their behaviour– this project will help them find the help they need.”

Breaking down barriers

To d ay’s expert:Prof Richard ByngPlymouth University PeninsulaSchools of Medicine and Dentistry

Real world solutionscan help break thecycle of re-offending

documenting their stories of suicideat t e m p t s.

Clearly, something needs to be donebefore and on release to provideformer prisoners with the supportstructure necessary for them to re-build their lives in a meaningful way,become part of society and turn awayfrom re-offending.

This issue, specifically with regardto former prisoners with mentalhealth problems, has been the focusof work carried out by our team atPlymouth University PeninsulaSchools of Medicine and Dentistry,together with other organisa-tions around the UK.

Our initial study, Care forOffenders: Continuity of Ac-cess (COCOA), was the firstsuch to systematically exam-ine healthcare received by of-fenders across the criminaljustice system and was pub-lished in 2012.

We concluded that existingservice configuration alongwith individual’s attitude and life-style both contribute to poor on-goingaccess to mental health support. So in2009 we asked ourselves the question:what would need to be done to helprecently-released prisoners re-entersociety successfully and break thecycle of mental illness and re-offend-ing?

The findings from COCOA and pi-lot work to show we could success-fully follow up prison leavers led to

funding of £2 million from the Na-tional Institute for Health Research(NIHR) Programme Grants for Ap-plied Research to carry out a five-yearprogramme to develop and evaluate asystem of care to address the prob-lems of obtaining mental health careon release.

The project aims to develop andevaluate a way of organising carebased on an integrated approach in-volving therapy, medication, hous-ing, training and employment, andensuring that care continues afterrelease. We are nearing the end of

phase one, which has seen research-ers working with people who havebeen in prison, the prison service andcommunity care providers to developthe model for an integrated approachto identify and engage prisoners be-fore release and then set up and de-liver care after release. The approachwill be tested, and elements of it ‘ro a dtested’, to ensure the best chance ofbenefiting prisoners.

The academic research team are

working with eight local men whohave served prison sentences. As‘peer researchers’ these men contrib-ute their life experiences to the re-search project. The group has beenable to use their experiences of beingin prison, and of the challengingtimes they experienced when theywere released, to support, inform andeven challenge the research team.They have worked alongside the aca-demic researchers to develop the pro-posed system of care, and advised onhow best to phrase the written ma-terials that participants will be giv-

en.The peer researchers

have met academic re-searchers fortnightlysince the autumn.They have helped torun and interpretfocus groups byc o m m u n i c at i n gwith other ex-offend-ers in ways in which theyfeel comfortable. They have en-

sured that the researchers are pro-ducing results that work in the realworld for people with similar exper-iences to themselves. They have alsocontributed to how, and what, thosetaking part can do for themselves tobuild on their own skills ands t re n g t h s.

The result is a matrix of activitiesthat we believe will make a real dif-ference. We start eight to 12 weeksbefore release to work on what we call

‘shared understanding’. This in-cludes two meetings between thesoon-to-be released prisoner, their su-pervisor and practitioner, where wereally get to grips with what linksthinking and emotions, behaviourand social outcomes for that indi-vidual.

For example, they may have anestablished cycle where, on release,they become anxious, deal with thatanxiety by becoming angry and endup getting into trouble. Conversely,anxiety might result in them notwanting to go out. They might justwant to get rid of stress, or simply

find a job – goals and objectivesare different for each indi-

vidual.We then move to the

“shared plan”, where wemobilise the resourcesthat already exist and are

available to address theneeds identified during the

shared understanding stage.This may involve GPs, friends, familyand organisations such as the Cit-izens Advice Bureau and employ-ment services.

We work through the shared planwhile the individual is still in prisonso that support is available on releaseand ‘through the gate’ challenges areaddressed (for example, avoiding theindividual heading straight for thepub or their dealer on release).

This is then taken forward as ac-tion in the community, where we help

the individual to re-engage with thecommunity, review their plan and setup working arrangements. The in-dividual is given a copy of their planso that they can share it with all thevarious practitioners (health, social,employment, etc) they will engagewith on and after release.

The second phase will be a ran-domised controlled trial in whichhalf the prisoners would receive thisnew approach while the others wouldreceive the care that is usually avail-able – very little.

By collecting information relatedto people’s health, the healthcarethey have received, improvements intheir social situation (includinghousing and employment) and theirinvolvement or otherwise with thecriminal justice system, we can eval-uate the effectiveness of the new in-tegrated approach by comparing itwith the results achieved by the usualsystem of care.

As well as investigating the be-nefits to released prisoners with men-tal health problems, we will also as-sess economic impact to see if therecould be savings to the public purse.

Will we change society’s attitudesto the ex-offender? Only time will tell.But we are confident that we arelaying the groundwork for a revolu-tionary new way to support prisonerswith mental health issues when theyare released. This has to be of benefitto them and, ultimately, to society as awh o l e.

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Something needs to be donebefore and on release toprovide former prisonerswith the support structurenecessary for them to rebuildtheir lives PROF RICHARD BYNG