Probation, Mental Health and Criminal Justice: Towards Equivalence 9781032044927, 9781032044934, 9781003193456

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Routledge Contemporary Issues in Criminal Justice and Procedure

PROBATION, MENTAL HEALTH AND CRIMINAL JUSTICE TOWARDS EQUIVALENCE Edited by Charlie Brooker and Coral Sirdifeld

Probation, Mental Health and Criminal Justice

This collection of research and evaluation explores issues in mental health and probation across the globe. The volume offers insight into a wide range of interrelated topics that address the mental health and mental health needs of those under probation supervision. The chapters embrace a range of diverse mental health concerns. The underpinning assumption is that offenders should receive mental healthcare that is ‘equivalent’ to that received by the general population where this is appropriate. This overview is informed by perspectives from academics and practitioners based in England and the Republic of Ireland, and also includes the views of people with lived experience of the Criminal Justice System. Building upon and adding to the existing literature in this feld, the book will be a valuable resource for academics and researchers as well as those training to work in, and currently working in, the criminal justice and mental health feld, and would also be of interest to those working in related healthcare settings. Charlie Brooker has an honorary chair in the Department of Law and Criminology at Royal Holloway, University of London. He was previously professor of mental health at both the Universities of Sheffeld and Manchester. He has published widely on the intersection between health and the Criminal Justice System including prisons, probation, policy custody, secure children’s homes and sexual assault referral centres (SARCs). Coral Sirdifeld is a Senior Research Associate at the University of Lincoln. She previously worked for the National Probation Service as part of a Lottery-funded project which employed nurses in probation offces to assess and address the health needs of people under probation supervision. She has been conducting research on understanding and addressing the health and social care needs of people in the Criminal Justice System since 2006.

Routledge Contemporary Issues in Criminal Justice and Procedure Series Editor Ed Johnston is a Senior Lecturer in Law, Bristol Law School, University of the West of England (UWE), UK.

The Law of Disclosure A Perennial Problem in Criminal Justice Edited by Ed Johnston and Tom Smith Challenges in Criminal Justice Edited by Ed Johnston Probation, Mental Health and Criminal Justice Towards Equivalence Edited by Charlie Brooker and Coral Sirdifeld In Defense of Juveniles Sentenced to Life Legal Representation and Juvenile Criminal Justice Stuti S. Kokkalera See more at https://www.routledge.com/Routledge-Research-in-Legal-History /book-series/CONTEMPCJP

Probation, Mental Health and Criminal Justice Towards Equivalence

Edited by Charlie Brooker and Coral Sirdifeld

First published 2023 by Routledge 4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 605 Third Avenue, New York, NY 10158 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 selection and editorial matter, Charlie Brooker and Coral Sirdifeld; individual chapters, the contributors The right of Charlie Brooker and Coral Sirdifeld to be identifed as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifcation and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record has been requested for this book ISBN: 978-1-032-04492-7 (hbk) ISBN: 978-1-032-04493-4 (pbk) ISBN: 978-1-003-19345-6 (ebk) DOI: 10.4324/9781003193456 Typeset in Galliard by Deanta Global Publishing Services, Chennai, India

This book is dedicated to Ella Syson-Nibbs, who died in 2021, and who would have been a university professor if she’d been born 20 years later.

Contents

List of tables and fgures Preface Acknowledgements List of abbreviations List of contributors 1 Probation, mental health and the Criminal Justice System: An introduction

x xii xiv xv xviii

1

CORAL SIRDIFIELD AND CHARLIE BROOKER

PART I

What is the evidence for effective mental health interventions in probation? 2 Mental health: A systematic review

5 7

CHARLIE BROOKER

3 Suicide: A systematic review

19

CORAL SIRDIFIELD

4 Substance misuse: A systematic review

36

CORAL SIRDIFIELD

PART II

How common are mental health problems in probation? 5 The Lincolnshire prevalence study CHARLIE BROOKER AND CORAL SIRDIFIELD

53 55

viii

Contents

6 Mental health among persons subject to probation supervision in Ireland

66

CHRISTINA POWER AND GERRY MCNALLY

PART III

Thematic reviews 7 Thematic inspection of individuals with mental health needs and disorders in the Criminal Justice System

79 81

LAURA BUCKLEY, AVTAR SINGH AND ROBIN MOORE

8 Substance misuse services and probation: A fractured relationship

95

KEVIN BALL AND LISA PARKER

PART IV

Psychological treatment 9 Psychological treatment and screening

107 109

JAMES FOWLER

10 New directions for suicide prevention in Approved Premises

126

KAREN SLADE

11 Autism and offending behaviour

141

ANDREW BATES

PART V

Probation and COVID-19

153

12 A view of probation and mental health after the pandemic

155

KERRY ELLIS DEVITT, DAVID COLEY, JESS LAWRENCE AND STACEY MUSIMBE-RIX

PART VI

Methodological issues

165

13 A lived experience perspective: Enhancing the work of probation through co-production

167

EMMA, JASON AND PHILIP MULLEN (REVOLVING DOORS AGENCY)

Contents ix

14 Researching the Probation Service response to mental health need

179

CORAL SIRDIFIELD AND DAVID DENNEY

PART VII

Conclusion

193

15 Conclusion

195

CHARLIE BROOKER, CORAL SIRDIFIELD AND DAVID DENNEY

Index

209

Tables and Figures

Tables 2.1 3.1 3.2 4.1 5.1 5.2 6.1 6.2 7.1 9.1 9.2 14.1

List of Papers Identifed in the Systematic Review as Background 10 Overview of Studies Included in the Systematic Review 22 Summary of Recommendations 29 Overview of Classifcation of Substance Misuse Studies Identifed in the Systematic Review 39 Results of Covariate Analyses Using Weighted Logistic Regression. Main Outcome, Any Current Disorder 59 Prevalence of Current Major Disorders and Likely Personality Disorder 59 Percentages across LSI-R Questions for Men and Women and Overall 67 Number and Percentages of Age and Gender in Study 1 and Study 3 70 Inspector Case-Level Judgements on Suffciency of Mental Health Needs Identifcation 86 Percentage of All Assessed Probationers Reporting an Affrmative Response in Most Recent Sample of 500 Clients 116 Signifcant Gender Differences in the Sample 120 Strengths and Limitations of Methodological Approaches 184

Figures 1.1 The main categories of probation order by year in England (recreated based on Ministry of Justice Report, 2020a) 2.1 Outcome of literature searching for systematic review on mental health 3.1 Outcome of literature searching for systematic review on suicide 4.1 Outcome of literature searching for systematic review on substance misuse

2 9 21 38

Tables and Figures xi

6.1 Percentages on health status issues for men, women and overall (study 2) 6.2 Percentages of symptoms indicative of mental health problems for men, women and overall (study 3) 6.3 Percentages of known mental health diagnoses identifed for men, women and overall 6.4 Percentages of key issues identifed presented for men, women and overall 6.5 Percentages of GAF ratings presented for men, women and overall 8.1 The decline in probation referrals for treatment from all sources for opiate dependency (Public Health England, cited by HM Inspectorate of Probation, Care Quality Commission, Healthcare Inspectorate for Wales, 2021) 9.1 Rapid Assessment and Support Form (RAS) 9.2 The proportion of all head injury cases where injury had been tested 9.3 Percentage of symptoms reported 9.4 Proportion of clients with previous substance misuse 9.5 Accommodation status of the sample 9.6 Previous and recent suicide attempts and self-harm 9.7 Gender of the probation sample 9.8 Action following assessment 10.1 Outline of Support and Safety Plan (SaSP) 10.2 Approved Premises CARE process fowchart 15.1 Principles to support the provision of high-quality mental healthcare for people on probation

69 70 71 72 72

98 112 117 118 118 119 119 120 121 131 133 204

Preface Lord David Ramsbotham

Professor Brooker and his colleagues are to be warmly congratulated, not only on their latest research, but also for their relentless pursuit of this important issue. The disastrous regime of Chris Grayling as Secretary of State for Justice from 2012 to 2015 and, in particular, his ill-named ‘Transforming Rehabilitation’ programme, against which he was strongly advised by his civil servants in an impact assessment which he chose to ignore, virtually destroyed the world-class Probation Service. His fxation with payment by results, and his attempt to privatise great chunks of the service, were calamitous in themselves. But, if he had bothered to learn anything about probation, he would have learned that the allimportant relationship between the offender and his or her supervisor is built on mutual trust, which cannot be privatised. I once asked Mr Grayling how his Rehabilitation Revolution differed from that of his predecessor, Kenneth Clarke’s, of the same title. ‘It will certainly be quicker’ came the response. It certainly was rushed, as many informed critics have pointed out, which contributed to the disaster, which will take many years to resolve. Not to mention the loss of experienced Probation Offcers, who cannot be replaced, as Transforming Rehabilitation was built on neither research nor pilot projects. Professor Brookers’ early research showed that only 18% of the NHS Clinical Commissioning Groups (CCGs) recognised that they had a responsibility for funding probation. Yet, as the Offce of National Statistics showed in its memorable report of 1997 on the mental health morbidity in prisons. Yet, as the Offce of National Statistics showed in its memorable report of 1997 on the mental health morbidity in prisons, the prevalence of mental illness amongst people in prison is high, and there is obviously a need to continue to provide mental health treatment that started in prison after release. Incidentally, I have never ceased to be amazed that the Home Offce, who were responsible for both prisons and probation at the time, did not relate the morbidity fgures in prisons to probation, then and there. To quote the recent Domestic Abuse Bill that has been through Parliament, there must be many victims of domestic abuse under probation supervision with speech and language needs, or suffering from acquired brain injury received during the abuse, who need continuing treatment.

Preface xiii I hope that this book, like Professor Brooker’s earlier reports, will be read, marked and learned by ministers and offcials in the Ministry of Justice and the Department of Health. I hope too that, as a result, anything like ‘Transforming Rehabilitation’ will be rejected on common sense grounds if nothing else.

Acknowledgements

Carl Finch, Dick Wiggins, Damian Mitchell, Beth Collinson, Kevin Gournay, Jay-Marie Mackenzie, David Milner, Gerry McNally, Christina Power, Tony Connell, Mark Gardner, Rebecca Marples, Imogen Schartau, Russell Webster, Sheila Paul, Meg Georgiou, Willem De Brugge (and CEP) and Christina Power.

Abbreviations

AAA ACCT ACE ADDER AMED AQ ASD ASSIA ATR AUDIT CAMHS Nurse CANFOR CANFOR-S CARE CCG CCN CINAHL CJS CMHT CPS CQC CRC CSSRI-EU CSTRs DA DAST DHSC DRR DTTOs DWP E&W

Adult Asperger Assessment Assessment, Care in Custody and Teamwork Adverse childhood experiences Addiction, Diversion, Disruption, Enforcement and Recovery (project) Allied and Complementary Medicine Database Autism Quotient Autistic spectrum disorder Applied Social Sciences Index and Abstracts Alcohol Treatment Requirement Alcohol Use Disorders Identifcation Test Child and Adolescent Mental Health Nurse Camberwell Assessment of Needs Camberwell Assessment of Needs (short version) Collaborative Assessment of Risk and Emotion Clinical Commissioning Group Collaborative Commissioning Network Cumulative Index to Nursing and Allied Health Literature Criminal Justice System Community Mental Health Team Crown Prosecution Service Care Quality Commission Community rehabilitation company Client Socio-demographic and Service Receipt Inventory – European Version Community Sentence Treatment Requirements Domestic abuse Drug Abuse Screening Test Department of Health and Social Care Disaster Risk Reduction Drug Treatment and Testing Orders Department for Work and Pensions England and Wales

xvi

Abbreviations

EDM EMBASE EQ ERT GAD-7 GAF HIMC HIW HMCTS HMI HMIP HMP HMPPS HSE IAA IBSS ICS IMV IPP KSS CRC LGBTQ+ LSI-R MAPIT MHCLG MHSE MHTRs MINI MoJ NHS NICE NOMS NPS OASys OPD ORA PHE PHQ-9 PPO PRS PTSD RAR RASS RCT SACPA SAPAS

Exceptional Delivery Model Excerpta Medica dataBASE Empathy Quotient Emotional regulation treatment Generalised Anxiety Disorder 7 Global Assessment of Functioning Health Institute for Mother and Child Healthcare Inspectorate Wales Her Majesty’s Courts and Tribunals Service Her Majesty’s Inspectorate Her Majesty’s Inspectorate of Probation Her Majesty’s Prison Her Majesty’s Prison and Probation Service Health Service Executive (Ireland’s health service) Implementation Assurance Audit International Bibliography of the Social Sciences Integrated Care Systems Integrated Motivational-Volitional Indeterminate Sentence for Public Protection Kent Surrey and Sussex Community Rehabilitation Company Lesbian, gay, bisexual, transgender, queer and other identities Level of Service Inventory – Revised Motivational Assessment Program to Initiate Treatment Ministry of Housing, Communities and Local Government Mental Health Service Evaluation Mental Health Treatment Requirements Mini International Neuropsychiatric Interview Ministry of Justice National Health Service National Institute for Health and Care Excellence National Offender Management Service National Probation Service Offender Assessment System Offender Personality Disorder Offender Rehabilitation Act Public Health England Patient Health Questionnaire 9 Prison and Probation Ombudsman Penal Reform Solutions Post-traumatic stress disorder Rehabilitation Activity Requirement Rapid Assessment and Support Service Randomised controlled trial (California) Substance Abuse and Crime Prevention Act Standardised Assessment of Personality – Abbreviated Scale

Abbreviations xvii SAQ SaSP SO SPSS SPTI SUs TR WHO WL YOT

Self-Assessment Questionnaire Support and Safety Plan Sexual offence Statistical Product and Service Solutions Brief suicide safety planning-type interventions Service users Transforming Rehabilitation World Health Organization Women’s Lead Youth Offending Teams

Contributors

Editors and contributors Professor Charlie Brooker, Honorary Professor, Royal Holloway, University of London, PhD, MSc, BA (Hons); [email protected] Dr Coral Sirdifeld, Senior Research Associate, University of Lincoln, PhD, MA, BA (Hons); [email protected]

Contributors Kevin Ball, BA (Hons), MA (HM Inspectorate of Probation) Andrew Bates, BA (Hons), MSc, Registered Forensic Psychologist (The Probation Service, South Central Region, UK) Dr Laura Buckley, BA (Hons), GradDip, MSc, PhD (HM Inspectorate of Probation) Dr David Coley, BA (Hons), MA, DProf (HM Prison and Probation Service) Professor David Denney, PhD, Emeritus Professor (Royal Holloway University of London) Dr Kerry Ellis Devitt, BA (Hons), MSc, PhD (University of Portsmouth) Emma, Lived Experience Team Member, Revolving Doors Dr James Fowler, PhD, CPsychol (St Andrew’s Healthcare) Jason, Lived Experience Team Member, Revolving Doors Jess Lawrence, BSc (Hons), MSc (HM Prison and Probation Service) Gerry McNally, Assistant Director, The Probation Service (Ireland). President of the Confederation European Probation (CEP) Dr Robin Moore, BA (Hons), MA, PhD (HM Inspectorate of Probation) Dr Philip Mullen, MArts, PhD (Revolving Doors)

Contributors xix Stacey Musimbe-Rix, LLB, LLM (HM Prison and Probation Service) Lisa Parker, DipSW, MBA, MA, BA (hons), Addiction and Inclusion Directorate, Department of Health and Social Care Dr Christina Power, BSc, MSc, DClinPsy Avtar Singh, BSc (Hons) Sociology and Applied Social Studies (HM Inspectorate of Probation) Prof Karen Slade, BSc (Hons), MSc, PsychD, CPsychol (Nottingham Trent University, HM Prison and Probation Service)

1

Probation, mental health and the Criminal Justice System An introduction Coral Sirdifeld and Charlie Brooker

In this book we will address issues related to those under probation supervision who may experience mental health conditions. Rethink, a charity in England, lists mental health conditions as follows: schizophrenia, psychosis, bipolar disorder, anxiety disorder/depression, dissociative disorder, eating disorder, personality disorder (including borderline personality disorder), post-traumatic stress disorder, drug and alcohol problems and obsessive-compulsive disorder (Rethink, 2021). We recognise that the above list relies heavily on medical diagnosis and that many people who experience mental health disorders do not fnd such classifcation helpful. However, it is useful to illustrate the breadth of formal diagnoses that may be considered in this feld. We have also chosen to consider research and practice relating to suicide here. People on probation arrive in this position in four main ways: the greater majority as a result of a community sentence; as part of serving a suspended sentence; those being supervised before release from prison and those being supervised after release from prison. The proportions of the probation population that ft these categories are given in Figure 1.1 (Ministry of Justice, 2020a). In 2020, there was a total population of 241,350 who were serving a probation order. The overwhelming majority of probationers are men (91%); the most common offences are theft and violence against the person (Justice Data, 2021). Of those who had their ethnicity recorded, 6% of those starting court order supervision by the Probation Service in England and Wales in 2019 self-identifed as Asian or Asian British, 7% as black or black British, 2% as Chinese or other ethnic group, 3% as mixed and 82% as white (Ministry of Justice, 2020b). Over the past 12 months, the delivery of probation services (and indeed the conduct of research) has been much hampered by COVID-19. The advent of the COVID-19 pandemic has impacted how we socialise and work. Some of us have been unable to work or to see people face-to-face for extended periods of time. Some of us have lost loved ones and many have been concerned for people who have tested positive for the virus. Evidence has already started to emerge around the detrimental impact on service users’ mental health during the pandemic. Probation (National Probation Service and Community Rehabilitation Companies) sought to sustain core services by implementing the Exceptional Delivery Model (EDM). However, the associated mental health challenges of this DOI: 10.4324/9781003193456-1

2

Coral Sirdifeld and Charlie Brooker 3,00,000

Number of offenders

2,50,000 2,00,000 1,50,000 1,00,000 50,000 0 Mar 2012 Mar 2013 Mar 2014 Mar 2015 Mar 2016 Mar 2017 Mar 2018 Mar 2019 Mar 2020 Community sentences

Suspended sentences

Pre-release supervision

Post-release supervision

Figure 1.1 The main categories of probation order by year in England (recreated based on Ministry of Justice Report, 2020a).

shift in operations for staff and people under supervision have been wide-ranging and complex. Drawing on data from a number of research studies and lived experience of working in a Community Rehabilitation Company, Chapter 12 fully explores these issues. COVID-19 notwithstanding, there is a growing impetus to consider the mental health status of those serving a probation order. In Chapter 5 the formal prevalence of mental health disorders in one English county is discussed, and in Chapter 6 there is an analysis of mental health need in the Irish Probation Service. It will be shown that, compared to the general population, prevalence, and therefore need, is high. Not only is prevalence high but the nature of disorders presenting in the probation population is complex as in the prison population. So not only is co-morbidity common but additionally there is likely to be a personality disorder present too. Co-morbidity, i.e., a mental health problem alongside substance use, is a major issue across the Criminal Justice System at a time when drug and alcohol services are seriously underfunded. The impact of drug and alcohol use in probation is examined in Chapter 8 drawing on the fndings of the most recent thematic review. In England too, there has been an ongoing thematic review of mental health across the Criminal Justice System which is reported on in Chapter 7 where the fndings from a joint inspection on mental health are considered. Led by Her Majesty’s Inspectorate of Probation, the inspection examined the quality and effectiveness of services for individuals with mental health disorders at various stages of the Criminal Justice System, namely arrest, police custody, charging

Probation and mental health 3 decisions, court, prison and probation. Individuals identifed as having mental health needs by probation services will also have their criminal justice journeys tracked backwards, examining whether their needs had been identifed previously by other organisations and adequately addressed. As well as looking at the quality of delivery in individual cases, the inspection will consider the key organisational enablers of leadership, staffng, services and information. Those with a mental health disorder are also at higher risk of killing themselves; it has been estimated that this risk in the general population is ten times higher when compared to those without a mental health disorder (San Too et al., 2019), for example. Thus, given the high prevalence rates of mental illness in the probation population (see Chapters 5 and 6), the high rate of suicide in the probation population is not surprising. Philips et al. (2018) have established that suicide rates in probationers are far higher than in the general population. In Chapter 10 this topic is addressed in the context of approved premises specifcally. Again, the work is part and parcel of a national policy initiative. Where care and treatment for mental health disorders, substance misuse and suicidality have been provided within probation settings world-wide we present three systematic reviews of the evidence for the effectiveness of those interventions. In Chapter 2 we outline a systematic review of mental health, in Chapter 3 the focus is on suicide and fnally in Chapter 4 we explore substance misuse. In short, there is a dearth of literature which might inform the delivery of effective interventions in probation in any of the three areas reviewed above, and there are very few descriptions of studies that have had an impact on health outcomes. One study that was published too late to be included in our systematic reviews concerned a targeted psychological intervention for probationers in London (Fowler et al., 2020). Aspects of this study are reported in Chapter 9. The paper is unusual in that a large section of the London probation population was screened using the Kessler-6 psychometric test (Kessler et al., 2002). Psychological intervention was then offered to those scoring above the threshold for a likely mental health disorder. In the study already reported in the literature there were signifcant improvements in symptoms and a signifcant reduction in re-offending. In their chapter, Fowler and colleagues focus on the effectiveness of the screening process and then evaluate three service delivery methods. This model seems very encouraging for those who are anxious or depressed. A separate paper, using assessment data from Fowler’s study and examining suicide, has also been published (Brooker et al., 2021). The book also acknowledges the important role to be played by experts in the feld of autism. Thus, in Chapter 11, there is a description of the development of policy and practice with UK probation services working with people with highfunctioning autism (e.g., where there is no learning disability) who have committed offences. Reference is made to the prevalence of autism in community forensic populations (approx. 3% from a study carried out in 2013) and typologies of typical offence types which may be committed by this group. A schedule for training probation staff to better understand and work with service users with autism is described, with its origins in an innovative and productive partnership

4

Coral Sirdifeld and Charlie Brooker

between a forensic psychologist employed by a probation Trust and a learning disability social worker specialising in autism. Finally, two chapters (13 and 14) focus on the methodological issues that occur when conducting research in probation settings. Chapter 13 looks at how co-production with service users might be developed and taken forward and the potential benefts of this. In Chapter 14, the authors examine the ambiguity of conducting research working in a system that has punitive controlling duties that can impinge on a person’s liberty but which also attempts to present a caring face. It is argued that the conduct of mental health research in this feld can leave investigators facing a complex set of conficting problems which are fully explored in the chapter. The concluding chapter offers a synthesis of the preceding material, presenting key points from each of the chapters and offering insight into potential future avenues to be explored in both research and practice. In particular we focus on healthcare expenditure on probationers, the complex needs that probationers can present with and whether or not the concept of healthcare equivalence is still a useful one in the context of offender mental health.

References Brooker, C., Tocque, K., West, G., Norman-Taylor, A., & Fowler, D. (2021) Suicide in probation: Towards the ideation-to-action model. Probation Journal. [Online] Available from: https://journals.sagepub.com/doi/full/10.1177/026 45505211041581 [Accessed 3rd May 2022]. Fowler, J. C., Price, R. C., Burger, K., Mattei, A. J., McCarthy, A. M., Lowe, F., & Sathiyaseelan, T. (2020) Embedding third sector psychology services within the probation environment: An alternative to MHTRs. Journal of Criminal Psychology, 10(1): 16–29. Justice Data. (2021) Probation data. Available from: https://data.justice.gov.uk/ probation [Accessed 15th February 2021]. Kessler, R. C., Andrews, G., & Colpe, L. J. (2002) Short screening scales to monitor population prevalence and trends in non-specifc psychological distress. Psychological Medicine, 32(6): 959–976. Ministry of Justice. (2020a) Offender management statistics offender management statistics quarterly: January, etc., - GOV.UK. Available from: www.gov.uk [Accessed 15th February 2021]. Ministry of Justice. (2020b) Offender management statistics quarterly, 30th April 2020. London: Ministry of Justice. Available from: https://assets.publishing .service.gov.uk/government/uploads/system/uploads/attachment_data/file /882167/Probation_2019.ods [Accessed 16th February 2021]. Philips, J., Padfeld, N., & Gelsthorpe, L. (2018) Suicide and community justice. Health and Justice, 6(1): 14. https://doi.org/10.1186/s40352-018-0072-7 Rethink. (2021) Learn more about mental health disorders learn more about the different mental health conditions. Available from: Rethink.org [Accessed 15th February 2021]. San Too, L., Spittal, M., Bugeja, L., Reifels, L., Butterworth, P., & Purkiss, J. (2019) The association between mental disorders and suicide: A systematic review and meta-analysis of record-linkage studies. Journal of Affective Disorders, 259: 302– 313. https://doi.org/10.1016/j.jad.2019.08.054

Part I

What is the evidence for effective mental health interventions in probation?

2

Mental health1,2 A systematic review Charlie Brooker

Introduction At the time of writing, a Thematic Review of mental health is underway across the whole of the Criminal Justice System in England and Wales. The last previous review into mental health took place ten years ago. The scoping paper for the Thematic Review notes that defning mental illness is problematic and opted for the defnition used by the Bradley review team (2009): Those who come into contact with the Criminal Justice System because they have committed, or are suspected of committing, a criminal offence, and who may be acutely or chronically ill. It may also include those in whom a degree of disturbance is recognised even though it may not be severe enough to bring it within the criteria laid down by the Mental Health Act 1983 (now 2007). The fndings of the Thematic Review in probation are outlined in Chapter 7 by Buckley and her colleagues. Here we present the main fndings from a narrative systematic review of mental health across the international literature. It is important that the mental health of those on probation continues to be a high priority because as demonstrated in Chapters 5 and 6 the needs in this group are high.

The aim of the systematic review The main aim of the review was to identify what the literature tells us about the most effective approaches to improving health outcomes for adults on probation. We also had a secondary aim of identifying what the literature tells us about: 1 This chapter is largely based on an article which was published in Forensic Science International: Mind and Law: Brooker, C., Sirdifeld, C., and Marples, R. (2019) Mental health and probation: A systematic review of the literature, Forensic Science International: Mind and Law, 100003. 2 This chapter is based on a study funded by the National Institute for Health Research (NIHR) Research for Patient Beneft Programme (Grant Reference Number PB-PG-0815-20012). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

DOI: 10.4324/9781003193456-3

8 ● ● ●

Charlie Brooker The health needs of people on probation Their patterns of service access Potential approaches to improving health outcomes that are being employed, but have not been subject to research or evaluation to date

What did the systematic review establish? In 2020, a narrative systematic review was published which aimed to identify research around the most effective ways of improving the mental health outcomes for people under probation supervision. The systematic review included a search of nine databases from January 2000 to May 2017, hand-searching of key journals from January 2000 to September 2017 and a search of the grey literature (see Brooker et al., 2020, for further details). In total, after an initial trawl, a total of 5,125 papers were initially identifed. After a series of reviews, this long list was whittled down to 24 papers for the background review section and 4 papers that presented research on improving mental health outcomes. We will address the overall poverty of outcomes-based mental health research in the discussion (Figure 2.1). The 24 papers that were included as background to the paper are listed in Table 2.1 alongside other key policy documents. In summary they explore six key areas: ● ● ● ● ● ●

Prevalence of mental health disorders Offending and mental illness Use of mental health services Treatment order imposed by the courts Partnership working between probation and mental health services Personality disorder pathways

There is a full description of these papers already published (Brooker et al., 2020), but there is some new and signifcant material that should be added especially in the area of treatment orders imposed by the courts in England. There has been a joint evaluation of Community Sentence Treatment Requirements (Mental Health Treatment Requirements, Alcohol Treatment Requirements and Drug Rehabilitation Requirements) by the Department of Health and Social Care (2019). The pilot was mounted in fve sites across England and aimed to: ●

● ● ● ●

Increase the use of Community Sentence Treatment Requirements (CSTRs), including increasing the use of combined CSTRs (Mental Health Treatment Requirements (MHTR) and Alcohol Treatment Requirements (ATR), MHTR and Drug Rehabilitation Requirements (DRR) Reduce the use of short-term sentencing Develop MHTR treatment availability Develop partnerships and effective steering groups Strive for sentencing on the day, wherever possible

Mental health

9

9 databases searched to identify literature about: • The most effective approaches to improving health outcomes for adults on probation • The health needs of adults on probation, their patterns of service access, and any potential approaches to improving health outcomes that are described in the literature, but have not been subjected to research or evaluation

5125 records identified on initial database searches

Duplicates removed, remaining 3316 cases assessed for inclusion

18 additional potential papers identified through hand searches

Full copies of 125 papers ordered: all potential includes (n=59) and background papers (n=66) Full copies read, 25 confirmed as includes, 84 classified as background, 14 excluded, and 2 unable to acquire

21 additional potential papers identified from the reference lists of the included studies, 20 are included, 1 is added to the background

45 includes

85 background papers

4 relate to mental health

24 relate to mental health

Figure 2.1 Outcome of literature searching for systematic review on mental health.

●

Increase awareness of the judiciary around mental health and associated vulnerabilities

In this section the focus will be only on the MHTRs. The drug and alcohol aspects are considered in Chapter 4. It should be noted that the evaluation did not focus on health or re-offending rates but rather examined the impact of implementation itself. The policy context for the new initiative has been recently summarised in A Smarter Approach to Sentencing (Ministry of Justice, 2020: 36) where it states:

10

Charlie Brooker

Table 2.1 List of Papers Identifed in the Systematic Review as Background Author(s)

Topic

Sirdifeld (2012) Brooker and Glyn (2012) Geelan et al. (2000) Melnick et al. (2008) Brooker et al. (2012) Huxter (2013) Bradley (2009) Melnick et al. (2008) NHS England (2016) Brooker et al. (2017) Pomeranttz (2003) Sodhi-Berry et al. (2014) Rodriguez et al. (2006) Skeem and Louden (2006) Robst et al. (2011) Konrad and Lau (2010) Khanom et al. (2009) Scott and Moffat (2012) Long (2016) Lamberti et al. (2004)

Prevalence of mental health disorders Prevalence of mental health disorders Prevalence of mental health disorders Prevalence of mental health disorders Prevalence of mental health disorders Use of mental health services Use of mental health services Use of mental health services Use of mental health services Use of mental health services Use of mental health services Use of mental health services Use of mental health services Offending and mental illness Offending and mental illness Treatment order imposed by the courts Treatment order imposed by the courts Treatment order imposed by the courts Treatment order imposed by the courts Partnership working between probation and mental health services Partnership working between probation and mental health services Partnership working between probation and mental health services Partnership working between probation and mental health services Personality disorder pathways Personality disorder pathways Personality disorder pathways Personality disorder pathways Personality disorder pathways Personality disorder pathways Personality disorder pathways

Mitton et al. (2007) Nadkarni et al. (2000) Clayton et al. (2013) Wetterborg et al. (2015) Minnoudis et al. (2011) Bui et al. (2016) Nichols et al. (2015) Blumenthal et al. (2009) Castledine (2015) Senior et al. (2011)

We will signifcantly increase the availability and usage of Community Sentence Treatment Requirements, to deliver tailored interventions to help support rehabilitation of those with mental health, drug and alcohol needs. Out of 889 offenders screened, 488 were recommended for probation; the bulk of those screened were for drug and/or alcohol problems (69%) and only 31% were screened for a mental health problem. Ultimately just 10% were subsequently

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given an MHTR although a further 14% were sentenced to a rehabilitation activity requirement (RAR) and an MHTR. Indeed, one site, Northampton, awarded no sole MHTRs at all. The treatment this small sub-group received was defned as: Mental health treatment as part of the primary MHTR pathway may involve a range of interventions, including psycho education, compassion focused therapy, cognitive behavioural therapy (CBT), behavioural activation, acceptance and commitment therapy, mindful practices and value-based solution focused therapy. No evidence base for the choice of these interventions is proffered nor is any information given about the therapists who delivered the intervention. The overarching concern was that the treatment was only directed to those with low-level mental health needs such as anxiety and depression, thus excluding those with co-morbidities, complex needs or a serious mental health problem. Many of those on MHTRs had also experienced signifcant levels of trauma which might lead to concerns about the appropriateness of the therapy offered. The data show that take-up of CSTRs overall increased but not hugely; hopefully there will be further data from the project focussing on mental health outcomes. A further new background paper of strategic importance is the relatively new health strategy for probation (HMPPS and NPS, 2019). The strategy sets out the objectives for the NPS as follows: ●

●

●

Increase training provisions for staff to support them to feel more confdent when managing individuals, under NPS supervision, with mental health problems Support timely and appropriate sentencing that adequately considers the mental health and wellbeing needs of individuals entering the Criminal Justice System, including supporting the use of CSTRs attached to a community sentence Strengthen partnerships at all levels to improve pathways into mental health treatment and services, particularly aiming to inform local commissioning processes for appropriate services that meet the needs of this complex cohort

It should be noted that since the strategy has been published there has been little operational detail on how the objectives might be achieved nor any notion about how to measure progress. The ongoing Thematic Review on mental health which is considered in Chapter 7 might throw some light on this observation.

The papers included in the systematic review Four studies on mental health met the criteria for inclusion in the review, i.e., addressed our primary goal of identifying what the literature tells us about the most effective ways of improving health outcomes for adults on probation.

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These studies were published between 2004 and 2016 in the UK (Hatfeld et al., 2004; Ramsden et al., 2016; Ryan et al., 2005) and the USA (Herinckx et al., 2005). The papers focused on the impact and learning from an Offender Personality Disorder Project (Ramsden et al., 2016), Approved Premises’ residents’ mental health needs and use of mental health services (Hatfeld et al., 2004; Ryan et al., 2005) and the impact of mental health courts on participants’ use of mental health services (Herinckx et al., 2005). All of these papers are described more fully below. In addition, one paper that was published after the review has been also included (Fowler et al., 2020). This reported an outcome study on the screening of people in a probation population for a mental health problem and then the delivery of a 12-session psychological treatment package.

The impact of an Offender Personality Disorder Project Ramsden et al. (2016) discussed the impact of an Offender Personality Disorder Project in one part of England. He looked at the impact on Offender Managers and probation practice through the use of case examples and analysis of data from 14 focus groups conducted with relevant health and probation staff. The project aimed to persuade probation and health staff to co-work in a new way. The project sought to achieve ‘psychologically informed case management’ to support individuals on probation with a personality disorder. Psychology staff produced case formulations with offenders and Offender Managers to inform the way in which they were supervised. The focus groups sought to highlight areas of good practice and also problems that might have arisen from working in a new way. The case examples showed how practitioners valued the partnership working and the sharing of expertise. The new modus operandi provided practitioners with a new way of looking at, understanding and working with risk. The psychologically informed model of practice aims to create an enabling environment for the offender and it is expected that risk will be reduced through an increased understanding of the offender’s behaviour. Whilst risk is an important factor, this is not the primary focus of the work. (Ramsden et al., 2016: 66) Initially there were concerns about the justifcation for this approach amongst probation staff, but these concerns were not present in later focus groups. The authors also provided some guiding principles for writing psychologically informed warning letters. Themes arising from the focus groups highlighted a concern on the part of Offender Managers – that the new way of working may impact Offender Managers’ professional identity. The semi-specialist Offender Managers working on the project were obtaining new skills but felt that at times this could either be isolating or might detract from their usual focus on risk management and public protection (Ramsden et al., 2016: 62). It also impacted their

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way of thinking about clients – potentially connecting more emotionally with the potential causes or triggers behind clients’ offending behaviour. As part of the project, the practitioners had been given reduced caseloads as part of the scheme to enable the new approach to be successful, but this was being threatened by changes resulting from Transforming Rehabilitation.

Approved Premises’ residents’ mental health needs and use of mental health services Two papers were included in the review that studied the mental health needs of residents in Approved Premises and their subsequent use of mental health services. Hatfeld et al. (2004) investigated the prevalence of mental health problems amongst residents of seven Approved Premises in Greater Manchester (n = 533 of 608 residents admitted between 1 May 2002 and 30 April 2003 and resident for at least seven nights), and their use of psychiatric services. Participants were aged 18–80 years, 89% were male and 11% were female, 93% were white, and they had committed a wide variety of types of offence. Just over a quarter of the residents in their sample had at least one known mental health diagnosis, and 41% of these had a second known diagnosis. Those with mental health needs had higher rates of psychological distress than those without. Whilst the majority of cases with psychotic illness lived in an Approved Premises with mental health support, there were cases with both severe and common mental health disorders that received no specialist support at all. Individuals with mental health needs who lived at either the specialist Approved Premises with mental health support or at the Approved Premises for women were signifcantly more likely to be receiving mental health services than those with mental health needs that were housed at the other Approved Premises (Hatfeld et al., 2004: 108). Ryan et al. (2005) conducted a follow-up study with a sample of 113 residents who had been identifed as having contact with mental health services in the above study and found that 75% of the sample had been referred to at least one mental health service after they left the Approved Premises, and twothirds of those leaving the Approved Premises were in contact with at least one mental health service at follow-up. However, there were 26 individuals who were not in contact with mental health services at follow-up, and staff felt that 12 of these should be receiving mental health support. The authors also note that their sample is likely to under-represent the true prevalence of people with mental health needs housed in probation Approved Premises as some residents’ mental health needs may not have been detected within the data collection period. Together, these two studies point to the high prevalence of mental illness amongst Approved Premises residents, and the value of both having good links between Approved Premises and primary care, and of having specialist Approved Premises for those with mental illness to improve access to care.

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The impact of mental health courts on participants’ use of mental health services Herinckx et al. (2005) studied the effectiveness of a mental health court in Clark County both in terms of criminal justice outcomes, and the impact of the programme on participants’ use of mental health services. A secondary analysis of data was conducted which compared service use 12 months pre-enrolment with service use 12 months post-enrolment for those enrolled between April 2000 and April 2003 (n = 368, with data on service use being available for 87% of these). Those included in the sample had an age range of 18–61 years, a DSM-IV Axis I diagnosis of major mental illness, did not have a developmental disability or an Axis II personality disorder, 56% were male and 44% were female, and 89% were Caucasian. The following types of service use were considered: case management, medication monitoring, intake and evaluation, individual therapy, group therapy, crisis intervention, inpatient treatment days and outpatient treatment days. The results showed that those participating in the court arrangements ‘received more hours of case management and medication management and more days of outpatient service after enrolment’ (Herinckx et al., 2005: 855), and ‘also received fewer hours of crisis services and fewer days of inpatient treatment after enrolment’ (Herinckx et al., 2005: 855). However, one must be cautious in interpreting these fndings as individuals who enrol in the programme and stay in it for at least 12 months may already have higher levels of motivation to make life changes than those who choose not to engage with the programme or who drop out (Herinckx et al., 2005). However, it remains one of the few studies in mental health that has examined service use over a prolonged period.

Third sector psychology services within the probation environment: an alternative to MHTRs Recently, an important paper was published based on the provision of psychological therapy to probationers in the London Community Rehabilitation Company (CRC) (Fowler et al., 2020). In his chapter in this book, James Fowler (Chapter 9) focuses intently on the effcacy of the screening process using data from 125 of those screens. Here, a brief outline will be given of the outcome of delivering psychological therapy, without resort to the use of CSTRs, to a probation sample that screened positive for a mental health problem using the K6 (those who scored over the threshold of 12 were referred to the in-house service). Here a 12-session psychological therapy was offered which is described as: Intervention was delivered by assistant psychologists in one-to-one sessions using a Cognitive-behavioural therapy manual … This manual, referred to as the Dealing with Feelings (DWF) manual, is based a form of CBT specifcally targeting emotional regulation skills. The DWF manual was developed for internal use in therapy for emotional dysregulation while in inpatient care by a mental health charity in the UK and is under copyright. The aim of the

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manual is to provide service users with a greater understanding of the presence and function of the full range of emotions. The programme requires 12 sessions to complete. The present study evaluates a service commissioned to implement this specifc mode of therapy based on the successful implementation of the MHTR pilot and as such, no other modes of therapy were implemented as part of this study. In the reported study, the clients participating were recruited at the earliest in August 2016, and had completed treatment no later than August 2017. At the outset, 569 clients scored over the threshold on the K6, 529 were advised to proceed to assessment, 228 did not attend the assessment appointment, leaving 301 who were assessed and 75 who completed treatment. Thus, there were signifcant levels of dropout throughout. In the sample of 75 who completed treatment, there were signifcant improvements in symptoms of mental ill-health such as anxiety and depression and signifcant reductions in re-offending. However, no information is given about what happened to a large group of 228 who screened positive and did not attend an assessment appointment. These would have been important fndings.

Conclusion The review shows that are very few studies that have looked at mental health outcomes in probation services despite the high prevalence of these disorders. The high prevalence is confrmed by the two studies of Approved Premises in Manchester. A handful of studies have attempted to do this but with mixed results. There are often high dropout rates with this group that makes longerterm follow-up problematic. The fve pilot sites for CSTR and the London CRC study have offered an intervention that has not been well described nor do we know much about the therapists delivering the intervention. Neither of the two studies are controlled, and the CSTR pilots raise issues of likely compliance and thus motivation. As far as we are aware, the role of mental health courts has never been tested in England, and although this study accrued signifcant benefts to the ‘court’ group, the question has to be posed: where is the user voice in all of this research? Maybe a new paradigm shift is required in the way that we perceive the appropriateness of mainstream mental health services? Just maybe, users should be engaged in designing such services?

References Blumenthal, S., Craissati, J., & Minchin, L. (2009) The development of a specialist hostel for the community management of personality disordered offenders. Criminal Behaviour and Mental Health, 19: 43–53. Bradley, K. (2009) The Bradley report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system. London: Department of Health.

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Brooker, C., & Glyn, J. (2012) Briefng 45: Probation services and mental health. London: Centre for Mental Health. Brooker, C., Sirdifeld, C., Blizard, R., Denney, D., & Pluck, G. (2012) Probation and mental illness. The Journal of Forensic Psychiatry and Psychology, 23(4): 522– 537. https://doi.org/10.1080/14789949.2012.704640 Brooker, C., Sirdifeld, C., & Marples, R. (2020) Mental health and probation: A systematic review of the literature. Forensic Science International: Mind and Law, 1: 1–9. https://doi.org/10.1016/j.fsiml.2019.100003 Brooker, C., Sirdifeld, C., Ramsbotham, D., & Denney, D. (2017) NHS commissioning in probation in England – On a wing and a prayer. Health and Social Care in the Community, 25(1): 137–144. https://doi.org/10.1111/hsc.12283 Bui, L., Ullrich, S., & Coid, J. W. (2016) Screening for mental disorder using the UK national offender assessment system. The Journal of Forensic Psychiatry and Psychology, 27(6): 786–801. Castledine, S. (2015) Psychologically informed and planned environments: A community perspective. The Probation Journal (The Journal of Community and Criminal Justice), 62(3): 273–280. https://doi.org/10.1177 /0264550515571398 Clayton, A., O’Connell, M. J., Bellamy, C., Benedict, P., & Rowe, M. (2013) The citizenship project part II: Impact of a citizenship intervention on clinical and community outcomes for persons with mental illness and criminal justice involvement. American Journal of Community Psychology, 51(1–2): 114–122. https://doi.org/10.1007/s10464-012-9549-z Department of Health and Social Care. (2019) Community Sentence Treatment Requirements Protocol: Process Evaluation Report. Available from: https://assets .publishing.service.gov.uk/government/uploads/system/uploads/attachment _data/fle/810010/cstr-process-evaluation-report.pdf [accessed 11th March 2021]. Fowler, J. C., Price, R. C., Burger, K., Mattei, A. J., McCarthy, A. M., Lowe, F., & Sathiyaseelan, T. (2020) Embedding third sector psychology services within the probation environment: An alternative to MHTRs. Journal of Criminal Psychology, 10(1): 16–29. Geelan, S., Griffn, N., Briscoe, J., & Haque, M. S. (2000) A bail and probation hostel for mentally disordered defendants. The Journal of Forensic Psychiatry, 11(1): 93–104. https://doi.org/10.1080/095851800362382 Hatfeld, B., Ryan, T., Pickering, L., Burroughs, H., & Crofts, R. (2004) The mental health of residents of approved premises in the Greater Manchester probation area: A cohort study. The Probation Journal (The Journal of Community and Criminal Justice), 51(2): 101–115. https://doi.org/10.1177/0264550504044169 Herinckx, H. A., Swart, S. C., Ama, S. M., Dolezal, C. D., & King, S. (2005) Rearrest and linkage to mental health services among clients of the Clark County mental health court program. Psychiatric Services, 56(7): 853–857. HMPPS and National Probation Service. (2019) National probation service health and social care strategy 2019–2022. London: HMPPS. Huxter, M. J. (2013) Prisons: The psychiatric institution of last resort? Journal of Psychiatric and Mental Health Nursing, 20(8): 735–743. Khanom, H., Samele, C., & Rutherford, M. (2009) A missed opportunity? Community sentences and the mental health treatment requirement. London: Sainsbury Centre for Mental Health.

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Konrad, N., & Lau, S. (2010) Dealing with the mentally ill in the criminal justice system in Germany. International Journal of Law and Psychiatry, 33(4): 236–240. https://doi.org/10.1016/j.ijlp.2010.06.005 Lamberti, J. S., Weisman, R., & Faden, D. I. (2004) Forensic assertive community treatment: Preventing incarceration of adults with severe mental illness. Psychiatric Services, 55(11): 1285–1293. Long, C. (2016) Realizing the potential of the mental health treatment requirement: A collaboration between probation and independent providers of mental health and social care. The Probation Journal (The Journal of Community and Criminal Justice), 63(4): 460–470. https://doi.org/10.1177/0264550516677061 Melnick, G., Coen, C., Taxman, F. S., Sacks, S., & Zinsser, K. M. (2008) Communitybased co-occurring disorder (COD) intermediate and advanced treatment for offenders. Behavioral Sciences and the Law, 26(4): 457–473. https://doi.org/10 .1002/bsl.827 Ministry of Justice. (2020) A smarter approach to sentencing. London: Ministry of Justice. Minoudis, P., Shaw, J., Bannerman, A., & Craissati, J. (2011) Identifying personality disturbance in a London probation sample. Probation Journal, 59(1): 23–38. Mitton, C., Simpson, L., Gardner, L., Barnes, F., & McDougall, G. (2007) Calgary diversion program: A community-based alternative to incarceration for mentally ill offenders. The Journal of Mental Health Policy and Economics, 10(3): 145–151. Nadkarni, R., Chipchase, B., & Fraser, K. (2000) Partnership with probation hostels: A step forward in community psychiatry. Psychiatric Bulletin, 24(6): 222–224. NHS England. (2016) Strategic direction for health services in the justice system: 2016– 2020. Leeds: NHS England. Nichols, F., Dunster, C., & Beckley, K. (2015) Identifying personality disturbance in the Lincolnshire personality (2020) disorder pathway: How do offenders compare to the London pilot? Probation Journal, 63(1): 41–53. Pomerantz, J. M. (2003) Treatment of mentally ill in prisons and jails: Follow-up care needed. Drug Beneft Trends, 15(6): 20–21. Ramsden, J., Joyes, E., Gordon, N., & Lowton, M. (2016) How working with psychologists has infuenced probation practice: Attempting to capture some of the impact and the learning from the offender personality disorder pathway project. Probation Journal, 63(1): 54–71. Robst, J., Constantine, R., Andel, R., Boaz, T., & Howe, A. (2011) Factors related to criminal justice expenditure trajectories for adults with serious mental illness. Criminal Behaviour and Mental Health, 21(5): 350–362. Rodriguez, J., Keene, J., & Li, X. (2006) A pilot study of assessed need and service use of offenders and frequent offenders with mental health problems. Journal of Mental Health, 15(4): 411–421. https://doi.org/10.1080/09638230600808061 Ryan, T., Hatfeld, B., Pickering, L., Downing, B., & Crofts, R. (2005) A follow up study of probation service approved premises residents in contact with mental health services. The Journal of Forensic Psychiatry and Psychology, 16(4): 699–713. https://doi.org/10.1080/14789940500294504 Scott, G., & Moffatt, S. (2012) The mental health treatment requirement: Realising a better future. London: Centre for Mental Health. Senior, J., Lennox, C., Noga, H., & Shaw, J. (2011) Liaison and diversion services: Current practices and future directions. University of Manchester: Offender Health Research Network.

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Sirdifeld, C. (2012) The prevalence of mental health disorders amongst offenders on probation: A literature review. Journal of Mental Health, 21(5): 485–498. https://doi.org/10.3109/09638237.2012.664305 Skeem, J. L., & Eno Louden, J. (2006) Toward evidence-based practice for probationers and parolees mandated to mental health treatment. Psychiatric Services, 57(3): 333–342. Sodhi-Berry, N., Preen, D. B., Alan, J., Knuiman, M., & Morgan, V. A. (2014) Presentence mental health service use by adult offenders in Western Australia: Baseline results from a longitudinal whole-population cohort study. Criminal Behaviour and Mental Health, 24: 204–221. Wetterborg, D., Långström, N., Andersson, G., & Enebrink, P. (2015) Borderline personality disorder: Prevalence and psychiatric comorbidity among male offenders on probation in Sweden. Comprehensive Psychiatry, 62: 63–70.

3

Suicide1,2 A systematic review Coral Sirdifeld

Introduction Suicide rates in England have increased since 2007, making suicide the biggest killer of men under 50 as well as a leading cause of death in young people and new mothers … The death of someone by suicide has a devastating effect on families, friends, workplaces, schools and communities. (HM Government, 2017: 4) The latest Offce for National Statistics data show that there were 4,303 suicides by men (16.9 deaths per 100,000) and 1,388 suicides by women (5.3 deaths per 100,000) registered in England and Wales in 2019 (Offce for National Statistics, 2020). The UK government has confrmed its commitment to the prevention of suicide, publishing a Cross-Government National Suicide Prevention Strategy in 2012 which was updated in 2017, and a Cross-Government Suicide Prevention Workplan in 2019 (HM Government, 2019). The strategy published in 2017 and subsequent progress reports recognised people in the Criminal Justice System as a high-risk group. Much has been written about risk and protective factors for suicide, and the potential role of different organisations in preventing suicide, including in secure settings such as prisons and mental health services. This chapter, which primarily draws on evidence from a recent systematic review, demonstrates the comparative dearth of probation-specifc studies in this area, and offers some insight into how the current gaps in the literature could be addressed in the future. It considers: ●

What is known about rates of suicide amongst people under probation supervision

1 This chapter is largely based on an article which was published in Forensic Science International: Mind and Law, 1, Sirdifeld, C., Brooker, C. & Marples, R. (2020), ‘Suicide and probation: A systematic review of the literature’, p. 100012, Copyright Elsevier. 2 This chapter is based on a study funded by the National Institute for Health Research (NIHR) Research for Patient Beneft Programme (Grant Reference Number PB-PG-0815-20012). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

DOI: 10.4324/9781003193456-4

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Coral Sirdifeld Risk factors associated with suicide in probation populations Contact with probation as an important opportunity for intervention What is known about approaches to reducing suicide amongst those under probation supervision

The systematic review: what do we know? In 2020, a narrative systematic review was published which aimed to identify research around the most effective ways of improving health outcomes for people under probation supervision, including suicide prevention. The systematic review included a search of nine databases from January 2000 to May 2017, hand-searching of key journals from January 2000 to September 2017 and a search of the grey literature (see Sirdifeld et al., 2020, for further details). The full review included papers that focused on individuals on parole, recently released prisoners and individuals who had been in the Criminal Justice System in the 12 months before suicide, i.e., had been ‘arrested, charged, convicted or serving either a community-based sentence or licence’ (King et al., 2015). Research papers, and papers that simply described the health needs of people in these groups and/or an approach to improving their health outcomes that had not yet been the subject of research or evaluation were included in the review. This resulted in a total of 12 descriptive (background) papers and 1 research paper about suicide and/or suicidal ideation being identifed within this wider review (Sirdifeld et al., 2020) (see Figure 3.1). Just six of these studies (fve background papers and one research paper) related specifcally to people under probation supervision, clearly demonstrating the paucity of research in this area. The following sections present fndings from these six studies, together with those from other key papers that were not identifed in this review (largely due to being published after the initial database searches were conducted). Studies included in the review and presented here are summarised in Table 3.1.

Rates of suicide amongst people under probation supervision The systematic review identifed one key study on rates of suicide amongst people under probation supervision. This study of death certifcates for 1,267 people serving community sentences or under post-custodial supervision by probation in England and Wales reported standardised mortality ratios for suicide or selfinficted deaths amongst males (n = 1140), showing that they had a ratio of 977 in 1996 compared to a standardised mortality ratio of 100 for the general population. In 1997 this had increased to 1,307 compared to 100, meaning that males in contact with probation were 13 times more likely to die by suicide than people in the general population (Sattar, 2003: 21). Drugs and/or alcohol contributed to around a third of these deaths (Sattar, 2003: 21). It is important to note that when looking at suicide/self-inficted deaths amongst those released from prison in this group, half of them had occurred within four weeks of release – suggesting that probation staff should be aware that risk is likely to be elevated during this period.

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9 databases searched to identify literature about: • The most effective approaches to improving health outcomes for adults on probation • The health needs of adults on probation, their patterns of service access, and any potential approaches to improving health outcomes that are described in the literature, but have not been subjected to research or evaluation

5125 records identified on initial database searches

Duplicates removed, remaining 3316 cases assessed for inclusion

18 additional potential papers identified through hand searches

Full copies of 125 papers ordered: all potential includes (n=59) and background papers (n=66) Full copies read, 25 confirmed as includes, 84 classified as background, 14 excluded, and 2 unable to acquire

21 additional potential papers identified from the reference lists of the included studies, 20 are included, 1 is added to the background

45 includes

85 background papers

1 relates to suicide

12 relate to suicide

Figure 3.1 Outcome of literature searching for systematic review on suicide.

These fndings are reinforced by those from other studies which were not included in the systematic review – a study conducted on a stratifed random sample of people under probation supervision in one region of England estimated that 32.4% (95% CI = 25.6–40.0) of those under supervision in this area had attempted suicide over their lifetime, and classifed 8.7% as being at high risk of suicide (Pluck and Brooker, 2014). A recent study reported that the rate of suicide amongst those under community supervision between 2010/2011 and 2015/2016 was nearly nine times higher than in the general population, and was also higher than amongst the prison population (Phillips et al., 2018). This refects fndings from an earlier

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Table 3.1 Overview of Studies Included in the Systematic Review Study

Sample

Key fndings

Themes in relation to risk factors Borrill Twenty-eight case records for suicide within the supervision et al. (2017) from one UK probation process included: (UK) area for deaths between 2010 and 2013 confrmed ● Missing probation appointments as suicide (n = 11) ● Stress when breach, legal or where ‘there was proceedings or enforcement actions substantial evidence of are instigated previous suicide attempts and other risk factors, along with increased suicidal motivation or low mood’ (p. 9) (n = 17). Records were examined from the start of the sentence until death. ● People under probation supervision Cardarelli 2,077 of 2,479 people who screened positive for et al. (2015) under probation anxiety disorder or bipolar were (USA) supervision who had a approximately twice as likely to be substance use disorder classifed as at high risk of suicide, assessment at Tarrant and those screening positive ‘for County Community depression were fve times more Supervision and likely to screen positive for suicide Correction Department’s risk’ (p. 149) Treatment Alternative to ● People under probation supervision Incarceration Program who screened positive for substance as part of The Mental abuse disorder were approximately Health Screening and twice as likely to be classifed as at Treatment Initiative. high risk of suicide Clark 18,260 records for people ● Shorter duration to mortality was associated with a history of et al. (2013) being monitored by suicide attempt, male gender, older (USA) community corrections age, white ethnicity and a history (probation or parole) of hospitalisation for a physical from 2002 to 2007. condition (p. 431) ● Identifed fve key themes around Mackenzie Thirteen probation staff staff experiences of working with et al. (2015) in one metropolitan service users who have attempted or (UK) area who had worked completed suicide, or self-harmed; with a service user how they manage their experiences, who had attempted or and if they feel that they have completed suicide or had suffcient knowledge and training self-harmed. for this work (Continued )

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Table 3.1 (Continued) Overview of Studies Included in the Systematic Review Study

Sample

Sattar (2003) (UK)

Death certifcates for 1,267 people serving community sentences or under post-custodial supervision by probation in England and Wales who had died in 1996 and 1997.

Yu and Sung (2015) (USA)

4,320 people aged 18+ years who participated in the National Survey of Drug Use and Health 2009–2011 and had been on probation during the 12 months prior to completing the survey.

Key fndings ●

●

●

●

●

●

●

●

Investigated modes of death based on death certifcates, which included those by suicide, and did not identify statistically signifcant differences in mode of death between males and females Standardised mortality rates for males for suicide/self-inficted injury show higher rates amongst the probation population than amongst the general population Overall there was a higher average annual prevalence of suicidal ideation amongst those under probation supervision (9.7%) than amongst those that were not under probation supervision (3.6%) (p. 426) There were differences between males and females on many characteristics including health status and access to healthcare Odds of suicidal ideation were increased for both men and women if they experienced serious psychological distress, inpatient mental health treatment or a major depressive episode Rates of suicidal ideation were higher amongst women than amongst men Odds of suicidal ideation amongst females under probation supervision doubled if they were black Suicidal ideation was increased in males under probation supervision who used illicit drugs

study, which also suggested that rates of suicide are higher in the probation population than amongst prisoners (Sattar, 2001). Finally, fgures published by the Ministry of Justice in December 2020 report 349 self-inficted deaths amongst those in contact with the National Probation Service or a Community Rehabilitation Company in 2019/2020 (Ministry of

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Justice, 2020). The accompanying data tool enables one to access information on other variables for these cases. This shows that 298 of these cases were male and 51 were female. The majority (n = 322) were white, with 7 recorded as mixed, 3 as black, 3 as Asian, 1 as other and 13 as unknown or not stated. In terms of age, 39 were aged 18–24, 118 were 25–35, 152 were 36–49, 35 were 50–65, 3 were over 65 and age was unknown in 2 cases. It should be noted that the defnition of ‘self-inficted deaths’ includes all deaths where it appears that someone has taken their own life, regardless of intent. Consequently, it includes some drug-related deaths, and these fgures are not directly comparable to those for rates of suicide in the general population produced by the Offce for National Statistics (Ministry of Justice, 2020).

Risk factors Several studies included in the review reported risk factors for suicide and suicidal ideation amongst people under probation supervision (Cardarelli et al., 2015; Clark et al., 2013; Yu and Sung, 2015). Cardarelli et al. (2015) conducted a study of people under probation supervision who had been assessed for a substance use disorder at Tarrant County Community Supervision and Correction Department’s Treatment Alternative to Incarceration Program. Information was collected around demographics, substance misuse and mental health using previously validated tools. Here, 13% of participants were classifed as at high risk of suicide because they answered positively in relation to this question: ‘Are you thinking about ending your life or committing suicide?’ (Cardarelli et al., 2015). After adjusting for confounders, the study found that women were around twice as likely as men to screen positive for high suicide risk, and probationers who screened positive for substance abuse disorder, anxiety disorder, or bipolar disorder were approximately twice more likely to be at high risk for suicide, and those who screened positive for depression were fve times more likely to screen positive for suicide risk. (Cardarelli et al., 2015: 149) Clark et al. (2013) investigated the relationship between prior suicidal behaviour and future risk of mortality using a dataset of records for 18,260 people being monitored by community corrections (probation or parole) in the USA from 2002 to 2007. A Cox Proportional Hazard survival analysis demonstrated that a self-reported history of attempted suicide is a key risk factor to consider in any suicide prevention work: Individuals reporting a history of suicide attempt (compared to those without a suicide history) demonstrated a shorter time to death while controlling for a number of other predictors … Positive history of suicide attempt was associated with the second-largest effect size in the model following male

Suicide 25 gender. Three other variables were found to be signifcantly associated with a shorter duration to mortality: older age, White race, and history of hospitalization for a physical condition. (Clark et al., 2013: 431) It should be noted that information on mental health diagnoses was not available in this study. Yu and Sung (2015) studied suicidal ideation amongst 4,320 adults who had participated in the US National Survey of Drug Use and Health 2009–2011. They provide a useful summary of research around suicidal ideation, attempted suicide and completed suicide risk factors in community corrections populations. Their study identifed a higher prevalence of suicidal ideation amongst people under probation supervision than amongst non-probationers. Here, the prevalence rate was higher amongst women than amongst men, and the odds of having suicidal ideation increased for women if they were black and experienced residential instability, and for men if they used illicit drugs. Experiencing a major depressive episode, and receiving inpatient mental health treatment were both identifed as predictors of suicidal ideation in both men and women. The one research paper included in the systematic review examined the pathways leading to suicide in a probation population. The research identifed 28 cases of either confrmed suicide or deaths where ‘there was substantial evidence of previous suicide attempts and other risk factors, along with increased suicidal motivation or low mood’ from probation records in one probation trust between 2010 and 2013 (Borrill et al., 2017: 9). Content analysis of information from the Offender Assessment System (OASys) and nDelius case management system associated with these cases led to identifcation of themes in relation to risk factors and the supervision experience of these individuals. Themes identifed included missed appointments which may ‘provide an observable sign that an individual is experiencing signifcant diffculties in coping and meeting their responsibilities and may be at risk of future suicide’ (Borrill et al., 2017: 15) and the stress associated with receipt of warning letters, or being the subject of breach and/or legal proceedings. This study notes that many people under probation supervision experience a complex range of needs and stressors. Whilst we may wish to be cautious in generalising from this study as it was conducted in just one probation area, it identifed four key themes which offer valuable insight into potential ways of improving suicide risk management in probation, and are further explored below. In addition, a study published recently examining a subset of cases in contact with probation in London and comparing individuals who had attempted suicide (actors), individuals with suicidal ideation and those with no history of attempted suicide or suicidal ideation (control) reported that ‘when suicidal actors and those with suicidal thoughts were compared to the control group a range of variables signifcantly differed including: general anxiety; severe depression; severe functional impairment; self-effcacy; lower problem-solving scores and use of mental health services’ (Brooker et al., 2021b: PAGE 9).

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Probation as an opportunity for intervention: what works to support people under supervision? As stated in the National Suicide Prevention Strategy 2017, no individual organisation can address all of the factors that may lead to suicide alone. However, we argue that probation, in partnership with other agencies, does have a role in suicide prevention. Unfortunately, identifying the most effective ways of reducing suicide in the probation population is an under-researched area. However, the research conducted by Borrill et al. (2017) suggests that collaborative supervision planning may be helpful in suicide prevention. Probation staff need to be mindful of the range of responsibilities that an individual may be juggling alongside those relating to their court order, which may include attending appointments with multiple agencies. Missed appointments may be an indicator of other issues that could be relevant to suicide risk such as bereavement or a loss of accommodation. Staff should be fexible where possible and consider the impact that changes to or clashes between appointment times and dates may have on a service user – for example making it diffcult to honour all responsibilities, and increasing stress levels. They should also be mindful that it may be benefcial to check on an individual’s well-being if they have missed an appointment. Secondly, in many cases, shortly before their death, the individuals in this study had received warning letters from probation and/or been subject to breach proceedings and/or legal proceedings. The research suggests that Practitioners should therefore consider whether risk of suicide could both be more likely and imminent in those face warnings or breach proceedings, when coupled with existing personal vulnerabilities. Routinely reviewing suicide risk when instigating the warning and breach processes could have the potential to contribute to suicide prevention. (Borrill et al., 2017: 16) Thirdly, changes in which probation or partnership agency staff an individual is working with may potentially be stressful for service users, and may increase risk, particularly when combined with other stressors. Whilst it may not always be possible to prevent a change in staff, it is something that agencies should be mindful of where possible. Finally, in cases where an individual presents a risk to self, a register should be activated in the nDelius system used by probation staff to ensure that all staff interacting with the individual are aware of the risk. However, in 26 of the 28 cases, this register had not been activated. Whilst the paper does not detail what, if any, difference this made in the two cases where it was activated, it suggests that this needs to change in future practice to ensure that information on risk is shared with all. Probation staff would beneft from training around the importance of using this register, and to support their role in suicide prevention.

Suicide 27

What works to support probation staff? As well as understanding the prevalence rates and risk factors for suicide amongst people under probation supervision, it is also important to consider the impact on probation staff of working with service users who have carried out or attempted suicide. Although the focus of the systematic review was on outcomes for those under supervision rather than staff, a qualitative study by Mackenzie et al. (2015) was identifed in the review, which explored the experiences of a purposive sample of 13 probation staff. Five main themes were identifed in this research. Whilst we must be cautious in generalising from the experiences of staff in one geographical area and time, the themes provide insight into participants’ views on potential indicators of suicide and self-harm, and what can be done to improve suicide prevention in probation settings, as well as the impact on staff. Firstly, understanding suicide and self-harm, which was informed by the past experiences and views that staff had of mental illness, and included participants’ thoughts on the potential purpose or motivation for self-harm. Here, there was a feeling that risk levels were less elevated in those who were open about their feelings, and higher in those who did not talk about them. ‘Repeat self-harmers or those with previous suicide attempts were regarded as less serious and less likely to eventually complete suicide, in contradiction with research fndings’ (Mackenzie et al., 2015: 115). However, some of these views could be infuenced by experience and/or training. Secondly, learning how to manage suicidal service users, where it was apparent that whilst training was available to staff, and mandatory for those working in Approved Premises, competing pressures meant that it was not always taken up, leaving staff feeling that they did not know the protocol for managing people who disclose suicidal feelings or self-injury. Thirdly, predicting the unpredictable – although suicide was seen as unpredictable, participants discussed trying to make sense of events, and potential indicators, which were complex and could include both personal (changing circumstances, changes to medication, stressful relationships, alcohol use, etc.) and criminal justice-related factors (such as awaiting sentencing and missing appointments). Fourthly, supporting suicidal service users, where it was apparent that some staff felt that it was good to talk to service users about their feelings, whereas others felt uncomfortable doing this, or thought that it may increase an individual’s risk of suicide. Support from mental health specialists was highly valued. Finally, support for staff, where it was apparent that staff were aware of the support that was available to them, but had varied views on how useful different kinds of support were. It is apparent that support is needed to enable staff to deal with feelings of guilt and powerlessness in relation to service users committing suicide. The study recommends that suicide prevention training should be prioritised for all probation staff working with offenders in the community.

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Moving towards equivalence This chapter has shown that rates of suicide in the probation population are considerably higher than those in the general population, and are also higher than those in the prison population. There is a dearth of research on the most effective approaches to reducing suicide in probation populations, and to supporting staff in working with service users with suicidal ideation. This needs to change. Probation staff are not continuously in contact with the people under their supervision, even those in Approved Premises. Consequently, preventing suicide in this population cannot be approached in exactly the same way as for populations in secure environments such as prisons. The sections below consider how probation’s role in suicide prevention is described in policy and what the literature tells us about how practice could potentially be improved. The recommendations are summarised in Table 3.2.

Improved use of data Policy and procedure documents make it clear that probation staff have a responsibility to: ●

●

Record when an individual under their supervision has died and participate in an internal review with their Senior Probation Offcer Record risk factors, consider and where possible address them in risk management plans (see, for example, HM Prison and Probation Service, 2020: 11)

In addition, probation wishes to ‘utilise internal and external data to understand the risk profle of the NPS service user population and utilise this to address identifed risks’ (HM Prison and Probation Service and National Probation Service, 2019: 16). Improved data is key to supporting these roles and ambition. Research highlights a need for the process following a death under supervision to be improved as forms are often completed in a defensive and cursory manner (Phillips, 2020). As Phillips (2020) argues, internal investigations could have an important role in preventing suicide if the focus is on identifying systemic obstacles to suicide prevention rather than attributing blame to individuals, and suffcient resources are invested to enable people to implement learning from these investigations (Phillips, 2020). A number of studies were shared in this chapter which identifed risk factors in relation to suicide in probation populations. These included substance abuse disorder, anxiety disorder, bipolar disorder, depression, a self-reported history of attempted suicide, residential instability and inpatient mental health treatment (Cardarelli et al., 2015; Clark et al., 2013; Yu and Sung, 2015). Overall risk and the impact of some of these factors were shown to vary by sex, age and ethnicity in some studies. Probation staff should record and respond to these factors

Suicide 29 Table 3.2 Summary of Recommendations Role/ambition

Recommendations

Improved use of data

●

Recording deaths Participating in internal investigations after deaths and implementing learning from this ● Recording, considering and where possible addressing risk factors Provide and undertake training ●

●

●

‘Raise awareness of suicide prevention and improve practice through developing the workforce’ (Her Majesty’s Prison and Probation Service and National Probation Service, 2019: 16) Partnership working, a fexible approach and research

●

●

‘Work with internal and external stakeholders to develop best practice and improve safety of NPS service users’ (Her Majesty’s Prison and Probation Service and National Probation Service, 2019: 16)

Provision of training which includes: Sharing what is known about risk factors and how probation staff and partner agencies can address some of them – including through the recommendations above ● Emphasising the importance of completing the Delius risk register ● What is expected of staff, and the procedures that they should follow to identify, record and respond to suicide risk ●

●

●

Investment of resources to enable learning from investigations to be implemented Research to investigate protective factors and predictors of the transition from ideation to action in a probation population Implementing Borrill et al.’s (2017) suggestions to check on well-being if someone misses an appointment or are subject to warning and breach processes

●

●

●

●

●

●

●

Probation staff to collect data on the health and social care needs of the probation population, the extent to which they are being met by current provision using established screening tools and share data with partner agencies Research into the reasons why some needs are not met and what services staff and those under supervision feel would be benefcial Long-term investment in services that meet the needs of the probation population are accessible to them – pilot a collaborative commissioning network Probation senior managers and health leads to establish clear referral pathways into support services Responding to recommendations from Borrill et al. (2017) and Mackenzie et al. (2015) for collaborative planning of appointments and continuity of supervisory relationships as far as practical and improved access to mental health specialists for probation staff Research into the impact of offering fexibility in how and how often people engage Evaluations of the above new approaches and interventions

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and following research by Borrill et al. (2017) and Sattar (2003) should also be mindful of: ● ●

●

●

Missed probation appointments as a potential warning sign The potential role of the stress associated with receipt of warning letters or being the subject of breach or legal proceedings The potential for risk to be elevated during the frst four weeks after release from prison The need to complete the nDelius risk register

Ideally data that are already recorded would be collated in a way that automatically fags suicide risk across probation systems. Introducing a clear measure around suicide risk would assist probation in meeting their ambition set out above. Further research is needed in this area. For example, research suggests that attempting to longitudinally predict suicidal thoughts and behaviours based on risk factors is problematic, and is likely to result in prediction that is only marginally better than chance (Franklin et al., 2017). Therefore, it would also be helpful if further work and research were undertaken to investigate protective factors in relation to suicide too. Furthermore, studies in prison populations have suggested that whilst most mental disorders may predict suicidal ideation, the range of disorders that are predictive of suicide attempt is more limited, with one study in New Zealand identifying only drug dependence, alcohol dependence and post-traumatic stress disorder (PTSD) as being associated with signifcantly increased odds of suicide attempt amongst prisoners reporting suicidal ideation (Favril et al., 2020). Indeed for male prisoners, ‘only PTSD distinguished attempters from ideators, independently of other disorders’ (Favril et al., 2020: 1150). Why this is the case is unclear, but ideation-to-action theories suggest that both a desire and capability for suicide are needed to act on ideation, and it may be that whilst illnesses such as depression are associated with a desire for suicide, substance misuse and PTSD may be associated with increased capability. Conversely it could be that PTSD develops in response to suicide attempts, and substance misuse is a maladaptive coping mechanism. Currently, to the author’s knowledge, there is no equivalent research examining predictors of the transition from ideation to action or the ideation-to-action model in a probation population.

Training The Probation Service in England and Wales wishes to ‘raise awareness of suicide prevention and improve practice through developing the workforce’ (Her Majesty’s Prison and Probation Service and National Probation Service, 2019: 16) and has already produced an Approved Premises Reducing Self-Inficted Death Action Plan 2018–2021.

Suicide 31 Suicide prevention training is available to probation staff but is not always taken up (Mackenzie et al., 2015). Ideally, further fnancial investments would be made in the Probation Service to ensure that suicide prevention is part of training for all staff, with the content being tailored to different roles and including mandatory updates for all staff (not just those working in Approved Premises) as appropriate. Whilst this recommendation is in no way novel, it is important. Training could support the service in meeting the above ambition, and may improve staff confdence in this area, and their understanding of the risk and (ideally) protective factors, including the raised risk presented during the frst four weeks after release from prison. Training should set out what is expected of staff, and the procedures that they should follow to identify, record and respond to suicide risk. It could also help to overcome some of the problems identifed in the research conducted to date, including the need to improve use of the nDelius risk register, and to ensure that staff understand that discussing suicide risk with a service user is unlikely to increase their risk. Also, they should not view risk as less serious amongst service users who have repeatedly self-harmed, or who have attempted suicide in the past (Mackenzie et al., 2015). Ideally, training would be conducted with local mental health service providers to enable staff within local probation and mental health services to form relationships and increase their understanding of each other’s roles.

Partnership working: a fexible approach and research The Probation Service recognises the importance of partnership working in suicide prevention through their ambition to ‘work with internal and external stakeholders to develop best practice and improve safety of NPS service users’ (Her Majesty’s Prison and Probation Service and National Probation Service, 2019: 16). Establishing clear partnerships between probation and local health services is essential if we are to reduce suicide in the probation population, and support staff in working with those who are at risk of, attempt and/or complete suicide. There are a number of reasons for this: ●

Targeted funding for appropriate service provision: appropriate service provision is required to support those who are considering suicide, and to reduce risk factors associated with suicide such as substance misuse problems and mental illness. Currently people under probation supervision encounter many barriers to accessing care, and there is very little investment from clinical commissioning groups in probation-specifc services (Sirdifeld et al., 2019a, 2019b). Those under supervision are able to access care as part of Community Sentence Treatment Requirements in some parts of the country, but it is unclear what, if any, impact this has on suicide prevention. Improvements in the appropriateness and accessibility of services will only be achieved if we (a) improve our understanding of the health and social care needs of people under probation supervision, the extent to which they

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●

●

Coral Sirdifeld are being met by current provision and the reasons why some needs are not met, and (b) have long-term investment in services that meet the needs of this group and are accessible to them. The systematic review demonstrates the paucity of research into what constitutes effective practice in this area. Improvements could potentially be achieved through investing in establishing a collaborative commissioning network similar to the one for Youth Offending Teams and conducting research to identify and trial models of mental health provision staff and those under supervision feel may effectively engage and support the probation population (Brooker et al., 2021a). Clear referral routes and procedures: it is important that staff have clear referral routes and procedures to follow to connect people under their supervision with appropriate service to offer immediate crisis support and to reduce suicide risk long-term, and to support those under their supervision who are bereaved by suicide. This can include (but should not be limited to) approaches to: ● Registering service users with a General Practitioner, who may be able to offer interventions or support directly, or act as a gateway to secondary care ● Making referrals to Community Mental Health Teams ● Directing service users to other support services, including self-support such as the Samaritans, the Campaign Against Living Miserably, or the StayAlive app ● Supporting service users to fnd stable accommodation ● Working with the NHS England RECONNECT where appropriate and available to support continuity of care for those being released from prison. ● Staff such as Heads of Community Integration and Health Leads within each probation region should be tasked with ensuring that these referral routes and procedures are in place. Collaborative planning: research demonstrates the diffculties that can arise when service users have multiple appointments at multiple agencies which clash with each other, or with other responsibilities that they have (for example to employers or family). Collaborative planning involving the service user, probation and other agencies involved in supporting the service user could help to minimise this problem and the stress that it causes. In addition, as detailed in the target operating model for probation services in England and Wales, research should be conducted on the impact of offering fexibility in how and how often people engage to identify any positive and negative outcomes from this approach (Her Majesty’s Prison and Probation Service, 2021). Whilst clearly there is a balance to strike with appropriate enforcement of a sentence, this does have potential to reduce the stress associated with some enforcement actions, and to give both staff and service users greater fexibility in terms of how they interact. Consistent relationships: Borrill et al. (2017) emphasised the benefts of probation and partner agencies offering continuity of supervision with the same personnel where possible, to avoid the stress of service users having

Suicide 33

●

●

●

to repeatedly share information and build relationships with new members of staff. It is encouraging to see this described as a key principle in the latest probation target operating model (Her Majesty’s Prison and Probation Service, 2021). Information sharing: where possible, established screening tools should be used to record data on health and social care needs and suicide risk. Data should be shared at aggregate level with partner agencies that commission and provide relevant support services. Support from mental health specialists: Mackenzie et al. (2015) suggested that probation staff really value input from mental health specialists. This could be achieved in a number of ways, for example, basing mental health specialists in probation settings, training some probation staff to become mental health specialists or including specialists on the national suicide prevention steering group for probation. Research and evaluation: there is currently very little research to support evidence-based practice around suicide prevention amongst people under probation supervision. Several areas for future research have been described above. In addition, new interventions and changes to practice should be accompanied by evaluations to evidence the impact on outcomes for service users and/or staff.

Conclusion It is clear that the rate of suicide is high in the probation population, and whilst no one agency can prevent suicide, probation does have a role in terms of: ● ● ●

●

Recording, investigating and learning from deaths Recording and responding to risk factors Working with partner agencies to facilitate access to services that may reduce risk factors and/or build on protective factors Developing the workforce to be confdent in working with those with suicidal ideation

There is a clear need for investment in probation, healthcare commissioners and providers, and research to: ● ● ●

● ●

Enable staff to attend training Embed learning from internal investigations following a death Collect and share data on service users’ health and social care needs (and in particular where these are currently unmet by local provision) Establish clear referral pathways and procedures into relevant partner agencies Improve understanding of: ● The most effective approaches to reducing suicide in the probation population, and supporting staff who work with those with suicidal ideation

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Protective factors Predictors of the transition from ideation to action The impact of new approaches and interventions such as collaborative commissioning networks, or different models of mental health provision on outcomes for staff and service users

References Borrill, J., Cook, L., & Beck, A. (2017) Suicide and supervision: Issues for probation practice. Probation Journal, 64(1): 6–19. Brooker, C., Collinson, B., & Sirdifeld, C. (2021a) Improving healthcare in adult probation services: Learning from youth offending teams. Probation Journal. [Online] Available from: https://journals.sagepub.com/doi/10.1177/0264550 5211070088 [Accessed 4th May 2022]. Brooker, C., Tocque, K., West, G., Norman-Taylor, A., & Fowler, D. (2021) Suicide in probation: Towards the ideation-to-action model. Probation Journal. [Online] Available from: https://journals.sagepub.com/doi/full/10.1177/026 45505211041581 [Accessed 3rd May 2022]. Cardarelli, R., Balyakina, E., Malone, K., Fulda, K. G., Ellison, M., Sivernell, R., & Shabu, T. (2015) Suicide risk and mental health co-morbidities in a probationer population. Community Mental Health Journal, 51(2): 145–152. Clark, C. B., Waesche, M. C., Hendricks, P. S., McCullumsmith, C. B., Redmond, N., Katiyar, N., Lawler, R. M., & Cropsey, K. L. (2013) The relationship between prior suicidal behavior and mortality among individuals in community corrections. Crisis, 34(6): 428–433. Favril, L., Indig, D., Gear, C., & Wilhelm, K. (2020) Mental disorders and risk of suicide attempt in prisoners. Social Psychiatry and Psychiatric Epidemiology, 55(9): 1145–1155. Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., Musacchio, K. M., Jaroszewski, A. C., Chang, B. P., & Nock, M. K. (2017) Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2): 187–232. Her Majesty’s Prison and Probation Service. (2021) The target operating model for probation services in England and Wales: Probation reform programme. London: Her Majesty’s Prison and Probation Service. Available from: https://assets .publishing.service.gov.uk/government/uploads/system/uploads/attachment _data/file/959745/HMPPS_-the_Target_Operating_Model_for_the_Future _of_Probation_Services_in_England___Wales_-__English__-_09-02-2021.pdf [Accessed 3rd March 2021]. Her Majesty’s Prison and Probation Service & National Probation Service. (2019) National probation service health and social care strategy 2019–2022. London: National Probation Service. HM Government. (2017) Preventing suicide in England: Third progress report of the cross-government outcomes strategy to save lives. London: Department of Health. HM Government. (2019) Cross-government suicide prevention workplan. London: HM Government. HM Prison and Probation Service. (2020) Risk of serious harm guidance 2020. London: Crown. Available from: https://assets.publishing.service.gov.uk/government/

Suicide 35 uploads/system/uploads/attachment_data/fle/897166/rosh-guidance-2020 .pdf [Accessed 2nd March 2021]. King, C., Senior, J., Webb, R. T., Millar, T., Piper, M., Pearsall, A., Humber, N., Appleby, L., & Shaw, J. (2015) Suicide by people in a community justice pathway: Population-based nested case-control study. The British Journal of Psychiatry, 207: 175–176. Mackenzie, J.-M., Cartwright, T., Beck, A., & Borrill, J. (2015) Probation staff experiences of managing suicidal and self-harming service users. Probation Journal, 62(2): 111–127. Ministry of Justice. (2020) Deaths of offenders in the community, England and Wales, 2019/20. London: Ministry of Justice. Offce for National Statistics. (2020) Suicides in England and Wales: 2019 registrations. Registered deaths in England and Wales from suicide analysed by sex, age, area of usual residence of the deceased and suicide method. London: Offce for National Statistics. Phillips, J. (2020) What should happen after the death of a probationer? Learning from suicide investigations in prison. Probation Journal, 67(1): 65–70. Phillips, J., Padfeld, N., & Gelsthorpe, L. (2018) Suicide and community justice. Health and Justice, 6(14). Pluck, G., & Brooker, C. (2014) Epidemiological survey of suicide ideation and acts and other deliberate self-harm among offenders in the community under supervision of the probation service in England and Wales. Criminal Behaviour and Mental Health, 24(5): 358–364. Sattar, G. (2001) Rates and causes of death among prisoners and offenders under community supervision. London: Home Offce. Sattar, G. (2003) The death of offenders in England and Wales. Crisis, 24(1): 17–23. Sirdifeld, C., Brooker, C., & Marples, R. (2020) Suicide and probation: A systematic review of the literature. Forensic Science International: Mind and Law, 1, 100012. Sirdifeld, C., Marples, R., Brooker, C., & Denney, D. (2019a) NHS commissioning in probation in England – Still on a wing and a prayer. Health and Social Care in the Community, 27(5): e697–e704. Sirdifeld, C., Marples, R., Brooker, C., Denney, D., Siriwardena, N., MaxwellHarrison, D., Strachan, S., & Connell, T. (2019b) Probation healthcare commissioning toolkit, a resource for commissioners and practitioners in health and criminal justice. Lincoln: University of Lincoln. Available from: www.probhct .blogs.lincoln.ac.uk Yu, S.-S. V., & Sung, H.-E. (2015) Suicidal ideation of probationers: Gender differences. Crisis, 36(6): 424–432.

4

Substance misuse1,2 A systematic review Coral Sirdifeld

Introduction ‘Substance misuse’ can refer to improper use of legal drugs and/or alcohol, use of illegal drugs, addiction and diagnosable substance use disorders. Research demonstrates the negative impact of some substance misuse on individual- and societallevel outcomes including for health, employment, criminal justice involvement and dependent children (Fox et al., 2011; Ministry of Justice, 2013; Public Health England, 2017). Preventing and addressing substance misuse is a multi-agency responsibility, and in England, drug and alcohol treatment services are commissioned from a variety of providers by local authorities from their public health grants based on local needs assessments. Funding for substance misuse services has been cut in recent times, and there is evidence to show that the harms caused by drug misuse are rising, with an independent review of drugs stating that: Drug deaths in 2018 were the highest on record (2,917). The increases have been primarily driven by deaths involving heroin, which have more than doubled since 2012, alongside a fve-fold increase in deaths involving cocaine or crack cocaine. We have seen the highest number of rough sleepers dying on our streets from drug poisoning since records began. Many of these deaths also involve alcohol. (Black, 2020: 7) Whilst criminal justice sanctions vary by time and place (Loue, 2003), often engaging in substance misuse or producing or supplying illegal drugs can directly lead to contact with the Criminal Justice System. Substance misuse can also 1 This chapter is largely based on an article which was published in Forensic Science International: Mind and Law, 1, Sirdifeld, C., Brooker, C. & Marples, R. (2020). ‘Substance misuse and community supervision: A systematic review of the literature’, p. 100031, Copyright Elsevier. 2 This chapter is based on a study funded by the National Institute for Health Research (NIHR) Research for Patient Beneft Programme (Grant Reference Number PB-PG-0815-20012). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

DOI: 10.4324/9781003193456-5

Substance misuse 37 indirectly lead to contact with the Criminal Justice System as it can be a driver for other forms of offending behaviour. For example, Kothari et al. (2002) report that ‘It is estimated that over 50 per cent of crime involves alcohol in some way’ and that many people engage in criminal activity to sustain drug use (Kothari et al., 2002: 412). Consequently, the Criminal Justice System is arguably an appropriate place to target substance misuse interventions. In England and Wales, probation has a role in identifying individuals with substance misuse problems to support appropriate sentencing, and in working with partner agencies to improve referral pathways for people with substance misuse needs (Her Majesty’s Prison and Probation Service and National Probation Service, 2019). This chapter primarily draws on evidence from a recent systematic review, and considers the role of the Probation Service in England and Wales and: ●

●

What is known about rates of substance misuse amongst people under probation supervision What support is available to people under probation supervision to address substance misuse, and what is known about how effective these approaches are

The systematic review: what do we know? A narrative systematic review was undertaken to (a) identify the international evidence on the most effective ways of providing healthcare to adults under probation supervision to improve their health outcomes, including those for substance misuse; and (b) to identify what is known about the health needs of adults on probation, their patterns of service access and any descriptions of (as opposed to research on) approaches to improving health outcomes. The systematic review included a search of the following databases from January 2000 to May 2017: MEDLINE, PsycINFO, IBSS, CINAHL, The Cochrane Library, EMBASE, AMED, ASSIA and HIMC. It also included handsearching of key journals from January 2000 to September 2017 and a search of the grey literature. There were no restrictions on language or study design (see Sirdifeld et al., 2020, for more details of how papers were assessed for inclusion and quality). The full review included papers focusing on a range of populations under community supervision, including those on parole, recently released prisoners and individuals with recent criminal justice involvement. A total of 15 descriptive (background) papers and 31 research papers about substance misuse were identifed within this wider review (see Figure 4.1 and Table 4.1). This chapter shares fndings from studies relevant to the areas listed above. For information on the remainder of the literature, see Sirdifeld et al. (2020).

Rates of substance misuse amongst people under probation supervision It is important that we understand the rates of different types of substance misuse amongst people under probation supervision as arguably these data are key

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9 databases searched to identify literature about: • The most effective approaches to improving health outcomes for adults on probation • The health needs of adults on probation, their patterns of service access, and any potential approaches to improving health outcomes that are described in the literature, but have not been subjected to research or evaluation

5125 records identified on initial database searches

Duplicates removed, remaining 3316 cases assessed for inclusion

18 additional potential papers identified through hand searches

Full copies of 125 papers ordered: all potential includes (n=59) and background papers (n=66) Full copies read, 25 confirmed as includes, 84 classified as background, 14 excluded, and 2 unable to acquire

21 additional potential papers identified from the reference lists of the included studies, 20 are included, 1 is added to the background

45 includes

85 background papers

31 relate to substance misuse

15 relate to substance misuse

Figure 4.1 Outcome of literature searching for systematic review on substance misuse.

to informing commissioning decisions. Just two background papers providing information on this topic were identifed in the review. They reported a high prevalence and complexity of substance misuse, with many people under probation supervision being found to experience both a substance misuse problem and a mental illness. Martyn (2012) reported fndings from a representative national survey of 2,963 cases in Ireland. This survey was completed by staff based on their knowledge of their cases and information contained in their case fles. Findings showed that 89% of cases were reported as having misused drugs and/or alcohol at some point, with prevalence rates for males and females being comparable. Overall, 27% were recorded as misusing drugs only, 20% as misusing alcohol only

Substance misuse 39 Table 4.1 Overview of Classifcation of Substance Misuse Studies Identifed in the Systematic Review Category Included in this chapter Prevalence of substance misuse amongst people on probation Descriptions of substance misuse services and interventions

Studies

Martyn (2012) Murphy and Sweet (2004) Fox et al. (2011) Murphy and Sweet (2004) Walters et al. (2014) Pharmacological and non-pharmacological treatments Brodie et al. (2009) and interventions Cropsey et al. (2011) Gray (2002) Gryczynski et al. (2012) Hollway et al. (2007) Drug Treatment and Testing Orders Eley et al. (2002) Mcsweeney et al. (2007) Powell et al. (2009) Turnbull and Webster (2007) Alcohol Treatment Requirements Ashby et al. (2010) Fox et al. (2011) Specialised courts Brewster (2001) Gottfredson and Exum (2002) Harrell et al. (2000) Kleinpeter et al. (2006) Mackin et al. (2008) Marchand et al. (2006) Martin et al. (2004) Martin et al. (2003) Stageberg et al. (2001) Predictors of treatment entry, retention and/or Alemi et al. (2006) outcomes Brown et al. (2013) Claus and Kindleberger (2002) Kelly et al. (2011) Kelly et al. (2013) Proposition 36, California Substance Abuse and Crime Anglin et al. (2013) Prevention Act (SACPA) Chun et al. (2007) Evans et al. (2014) Longshore et al. (2005) The role of probation Hearnden (2000) Not included in this chapter The impact of treatment readiness and of coerced or Gregoire and Burke (2004) mandatory treatment Kelly et al. (2005) Sia et al. (2000) Walters et al. (2014) Risk factors for engaging or re-engaging in substance Hall et al. (2016) misuse Winter et al. (2016) Harm reduction from treatment Carter et al. (2000) Nicosia et al. (2016) Small (2007) Policy commentary Collins et al. (2016) Gyngell (2011) Joseph et al. (2000) Small (2007)

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and 42% as misusing both drugs and alcohol. Staff believed that drug misuse was linked to an individual’s current offence in 74% of cases. The equivalent fgure for alcohol misuse was 71.3%. Murphy and Sweet (2004) illustrated the complexity of substance misuse amongst people under probation supervision, reporting poly-drug abuse as being prevalent amongst initial referrals to a partnership between probation and a community addiction service in Northern Ireland. Here, ‘cannabis, ecstasy and benzodiazepines, invariably along with high levels of alcohol consumption, are prominent’ and ‘early results indicate high levels of dependency on alcohol, though only medium levels of dependency on illicit drugs. In addition, the individuals assessed to date evidence moderate to severe levels of co-morbid depression’ (Murphy and Sweet, 2004: 16). Similarly an additional study (not identifed in the review) conducted on a stratifed random sample of people under supervision in one English probation area reported that 60% of the sample (95% CI [52.8, 67.4]) screened positive for substance abuse. This was defned as scoring 11+ on the Drug Abuse Screening Test short version and/or 8+ on the Alcohol Use Disorders Identifcation Test (AUDIT). Participants were more likely to screen positive for alcohol misuse (55%, 95% CI [[48.1, 62.9]) than drug abuse (12.%, 95% CI [7.3, 17.0]) which may be indicative of a true difference in prevalence rates, or of a difference in self-report. This study also reported a prevalence rate of co-morbidity of mental illness and likely alcohol abuse of 66%. The equivalent fgure for drug abuse was 21% (Brooker et al., 2012).

Probation as an opportunity for intervention: what support can people access and what works? The research above demonstrates that there is a high prevalence of substance misuse in the probation population, but what impact can probation have on substance misuse, and what services can people under probation supervision access in England and Wales and how? Hearnden (2000) interviewed 278 people under supervision and 15 Probation Offcers in the UK to explore the role of probation and other interventions in reducing drug misuse. A comparison of self-report data on drug misuse and offending in the four weeks prior to arrest with the four weeks prior to interview showed a signifcant fall in drug use including injecting and associated expenditure whilst on probation, together with a reduction in crime. However, this was not straightforward, for example, half of the sample continued to use heroin. People under supervision reported that probation had had a positive impact in supporting reductions in drug misuse, with 90% reporting being offered assistance by an Offcer, and over half feeling that their Offcer had been a great deal of help. However, 20% said probation assistance had not made any difference, and 60% felt that personal rather than probation-related factors had the most infuence on their levels of drug use. Some staff and people under probation felt that staff would beneft from more training. People under supervision thought

Substance misuse 41 that support could be improved through provision of rehabilitation units and counselling, particularly from ex-users; whilst staff felt that it could be improved through more consistent provision of on-site services, and more fexibility around enforcing National Standards. Currently, people under probation supervision can currently access pharmacological and non-pharmacological treatment and interventions in the same way as the general population. The systematic review identifed just fve studies of the effectiveness of such interventions specifcally in individuals with criminal justice involvement: vigabatrin for parolees with cocaine dependence (Brodie et al., 2009), methadone or levo-alpha-acetylmethadol for individuals under probation supervision with heroin dependency (Gryczynski et al., 2012), buprenorphine for women on probation or parole with dependency on opioids (Cropsey et al., 2011), a residential addiction treatment programme in Ireland (Hollway et al., 2007) and the Brooklyn Program – a 16-week programme available for people under federal supervision (Gray, 2002). Unfortunately, as all of these studies examine different types of intervention with different samples, and different outcome measures, it is impossible to draw conclusions about the most effective approaches from this literature. There is evidence to support the effectiveness of a wide range of treatments in reducing both substance misuse and offending. However, as noted in an evidence review on treatment for drug misuse, It is a formidable challenge to synthesise this body of research – not least because of differences in the time and place of each study, the populations sampled, the design and quality of the research conducted, the treatment interventions evaluated, and outcomes studied and interpreted. (Public Health England, 2017: 43) Analyses of the available evidence for drug misuse treatment can be found in chapter three of the above evidence review, and a recent systematic review and meta-analysis of 22 studies of pharmacological interventions for drug-using offenders (Glanville et al., 2021: 1; Public Health England, 2017). Another option for eligible individuals is to consent to access treatment via court-ordered interventions. Drug Treatment and Testing Orders (DTTOs) were introduced into England and Wales via the Crime and Disorder Act 1998, and later introduced into Scotland. Through a partnership between probation, the courts and treatment services, these orders aimed to support reductions in substance misuse and associated offending behaviour amongst individuals whose offending was driven by drug misuse. The literature on DTTOs suggests that they had a positive impact on reducing drug misuse and offending behaviour and improving health outcomes (Eley et al., 2002; Mcsweeney et al., 2007). However, they have now been replaced by Drug Rehabilitation Requirements (DRRs) – one of several Community Sentence Treatment Requirements (CSTRs, which also include Alcohol Treatment Requirements (ATRs) and Mental Health Treatment Requirements (MHTRs)) available to be given as part of a community or suspended sentence order in some areas of England and Wales.

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To date, use of CSTRs has been low, and they are not available in all regions, but the UK government plans to expand their availability (Ministry of Justice, 2020). Parallels can be drawn between the challenges for delivering DTTOs evidenced in the literature, and the challenges faced in delivering CSTRs today. Challenges include poor resourcing and limited availability of treatment constraining sentencers’ ability to use CSTRs, the need for clear roles in partnership working, debate over how realistic a goal total abstinence is (harm reduction may be a more appropriate aim) and the need for clear communication and agreement about who should receive an order (Department of Health and Social Care, 2019; Khanom et al., 2009; Mcsweeney et al., 2007; Turnbull and Webster, 2007). Two papers on ATRs were identifed in the review. Fox et al. (2011) provided a prospective model of the economic costs and benefts of introducing ATRs in Stockport, UK. Here ATRs were targeted towards individuals aged over 25 years who scored over 20 on the Alcohol Use Disorders Identifcation Test (AUDIT), had an offender group reconviction scale score over 50, were tiers 2–4 in the offender management model, where the seriousness of harm was judged to be medium or high, the likelihood of reoffending is judged to be very high and will happen if alcohol use is not addressed and the individual had committed a serious violent or public order offence. The researchers estimated the cost per client as £1,700 with the potential for economies of scale if it was rolled out over a wider region, and estimated that if a client did not consume alcohol or re-offend for a year after sentence, conservative cost savings of £12,881 for the criminal justice sector and £1,400 for the health service would be gained. Break-even point was reported as a 12% reduction in reoffending. Ashby et al. (2010) examined probation and treatment agency data for 81 people who had completed or were close to completing an ATR. Assessments by alcohol treatment workers suggested that 54% had made positive changes to their drinking levels and behaviour, nearly a third (32%) were abstinent, and 11% had achieved ‘controlled alcohol consumption’, and 11% had reduced their consumption. However, 16% were not engaging with treatment and were continuing to drink, and 14% had relapsed or deteriorated. The study also showed that 7% of those completing the ATR were referred to mental health treatment – highlighting the need for services designed to work with those with dual diagnosis. Specialised courts (drug courts, alcohol courts and dual diagnosis courts, also known as ‘problem-solving courts’) have been established in some parts of the world, and mainly offer participation in a treatment programme involving regular attendance with probation, the court and a treatment provider, and substance misuse testing as an alternative to incarceration. A relatively large body of literature on this topic was identifed in the systematic review (see Table 4.1), and positive outcomes are reported from these studies. It is diffcult to draw frm conclusions from this literature however, due to the possibility of selection bias, and the variation in eligibility criteria, the length and content of programmes offered and referral processes. An evidence review conducted in 2015 concluded that ‘there is strong evidence that adult drug courts reduce substance misuse and reoffending. They are particularly effective with offenders who present a higher

Substance misuse 43 risk of reoffending’ (Bowen and Whitehead, 2015: iii), whilst a paper published in 2020 concluded that ‘The public health beneft of these courts is questionable, especially with regard to the urgent need in the country for access to scientifcally sound treatment for opioid use disorders’ (Csete, 2020: 4). Problem-solving courts are now being piloted in the UK (Ministry of Justice, 2020). In addition to the above, the Home Offce have recently funded a multiagency pilot project called Project ADDER (Addiction, Diversion, Disruption, Enforcement and Recovery), which aims to reduce the amount of drug use, and drug-related deaths and offending and will be subject to an evaluation.

Other approaches and success factors Can we learn anything from the literature identifed in the review about approaches that have been successfully used in other countries, and factors that underpin successful interventions? In California, a state-wide policy to divert offenders with substance misuse problems to probation with drug treatment (instead of incarceration or probation without treatment) was introduced called Proposition 36, California Substance Abuse and Crime Prevention Act (SACPA). A range of treatment types are available under the programme. SACPA differs from drug courts in that eligibility is based solely on conviction-based eligibility criteria (although these criteria vary between counties), whereas drug courts were also able to specify additional eligibility criteria such as addiction severity. In addition, SACPA participants cannot be imprisoned for non-compliance (instead they receive three opportunities to re-enter treatment). The programme is reported to have impacted positively on access to and engagement with treatment, and to have produced cost savings, although outcomes are variable (see, for example, Anglin et al., 2013; Chun et al., 2007; Evans et al., 2014; Longshore et al., 2005). Treatment completion is reported to vary by ethnicity, age, primary drug of choice, years of drug use and whether an individual is on probation or parole (see Longshore et al., 2005). A number of background papers were identifed in the review that described (as opposed to fully evaluated or researched) substance misuse services or interventions working with people under probation supervision. These services and interventions could be the subject of future research. Murphy and Sweet (2004) described the Rapid Assessment and Treatment Service for Drug and Alcohol Misusers – a partnership between the Probation Board of Northern Ireland and the Northern Ireland Community Addiction Service. The project was established to provide assessment and treatment for people under probation supervision with substance misuse problems. Referrals could be made by probation at pre-sentence or for those already under supervision where it appeared that offending behaviour was linked to drug misuse. Referrals were then assessed using the Short Alcohol Dependence Data questionnaire to assess the severity of alcohol dependence, the Severity of Alcohol Dependency Questionnaire, the Leeds Dependence questionnaire to measure illicit drug dependence, the Beck Depression Inventory version two and the Stages of Change questionnaire

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to measure attitudes towards making changes in relation to substance misuse. Individuals who were accepted into the programme (around half of the 71 referrals made when the paper was published) then received individual counselling sessions involving cognitive behavioural therapy and motivational interviewing. Those who were viewed as unlikely to beneft from this could be referred into other types of provision. There were plans to evaluate the impact of this service when this paper was published. Jason et al. (2015) compared outcomes for 270 adults who had been in jail or prison, were recovering from drug or alcohol dependence and were randomly assigned to a therapeutic community, a recovery home (known as Oxford Houses and providing supported living that encourages abstinence, but not providing treatment) or a usual care setting. Individuals who had committed violent or sexual offences, or who did not accept random assignment were not eligible for the study. Findings showed that having more days in a therapeutic community or a recovery home was associated with fewer days using drugs and fewer days using alcohol. The recovery homes achieved higher rates of continuous abstinence from alcohol than the other conditions. There were no statistically signifcant differences in rates of continuous abstinence from drugs across the three conditions. Walters et al. (2014) described a web-based intervention to increase motivation to enter substance misuse treatment (MAPIT). This consisted of two sessions: The frst session (completed near the start of probation) targets motivation to complete probation, to make changes in substance use (including treatment initiation), and to obtain HIV testing and care. The second session (completed approximately 30 days after session 1) focuses on goal setting, coping strategies, and social support. (Walters et al., 2014: 60) Findings from a pilot with 21 people who would have been eligible to access the intervention suggested that it may improve criminal justice and treatment outcomes, and further testing in a randomised controlled trial was planned. Five papers were identifed in the review which identify various factors about how interventions are delivered which may infuence outcomes (Alemi et al., 2006; Brown et al., 2013; Claus and Kindleberger, 2002; Kelly et al., 2013; Kelly et al., 2011). Three of these studies provide fndings around the infuence of where an intervention is delivered which may be worthy of study in the UK. Brown et al. (2013) conducted a small-scale feasibility study that compared outcomes for buprenorphine opioid substitution therapy delivered in specialist facilities and in primary care. Findings suggested that delivery in primary care may be effective in terms of reducing illegal drug use, and potentially in terms of reducing HIV risk behaviours (Brown et al., 2013). Alemi et al. (2006) compared ‘seamless’ substance misuse treatment, where probation staff are involved in treatment or co-located with treatment staff, and ‘traditional probation’ where the person under supervision is able to choose whether or

Substance misuse 45 not to access treatment outside of the Criminal Justice System. Individuals receiving seamless treatment spent more days in mental health hospitals than the traditional group, but spent fewer days in physical health hospitals. When considering both health and criminal justice outcomes combined, the researchers concluded that seamless probation is not more cost-effective than traditional probation. Claus and Kindleberger (2002) investigated factors infuencing treatment entry and drop out for an opportunity sample of individuals who had been assessed at a central intake unit and matched to an appropriate treatment provider (n = 260). This study showed that individuals receiving residential treatment were more likely to attend and to stay in treatment than those receiving outpatient treatment.

Moving towards equivalence This chapter has shown that in England and Wales, people under probation supervision are largely expected to access substance misuse services in the same way as the general population. In addition, in some regions, those who meet eligibility criteria may also consent to access services via CSTRs or may have the option of attending a problem-solving court. At present, further research is needed to fully evidence the health and criminal justice outcomes of CSTRs and problem-solving courts in England and Wales. Public Health Outcomes Framework data indicate that the proportion of adults with substance misuse treatment need that successfully engaged in community-based structured treatment following release from prison in 2019/2020 was 34.5%. This fgure is particularly concerning given the increased risk of relapse and drug-related deaths following release from prison (Kothari et al., 2002). An audit conducted in London to identify barriers to continuity of care highlighted several challenges around the ability of prison staff to refer into community-based services; frst, approximately half of referrals made by the prison were not received by the community-based services and no checks were conducted to confrm that they had been received. Second, prison staff sometimes received limited notice that someone was going to be released. Additionally, when referrals were made, attendance at community-based services was low, and there was no follow-up of non-attenders, at least in part due to a lack of contact details for individuals following release. However, attendance rates were high (80%) if individuals were contacted by the community-based service prior to their release from prison (Public Health England, 2018). Ensuring continuity of care is an issue that the NHS England RECONNECT – Care After Custody project has set out to address. Probation staff can also help to improve continuity of care, and also to improve engagement with treatment amongst those receiving non-custodial sentences issue through: ● ●

Engaging with the RECONNECT project Following up on non-attendance when referrals have been made

46 ●

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Coral Sirdifeld Fulflling the ambition set out in the Health and Social Care Strategy to ‘work with partner agencies to strengthen local referral pathways for those who may beneft from substance misuse services, including improving pathways into the community for those receiving substance misuse treatment in prison’ (Her Majesty’s Prison and Probation Service and National Probation Service, 2019: 14) Assisting people under supervision to register with a GP – removing another potential barrier to accessing care

It is also clear that there is a need for increased investment in service provision. Dame Carol Black’s Review of Drugs pointed to signifcant reductions in spending on treatment – with investment falling by as much as 40% in some areas. Alongside this, there has been a loss of skills and expertise in this feld. Moreover, previous research has evidenced the diffculties faced by people with co-occurring mental health and substance misuse in accessing services as often provision is only set up to address a single issue. Increased spending, preferably through ring-fenced funds, will be necessary to support the wider rollout of CSTRs as well as to ensure that services are available through other routes. Probation can have a role in ensuring that spending is well targeted to support the people on their caseload through collecting and sharing robust data on the health and social care needs of people under supervision and sharing these (at aggregate level) with local commissioners to inform joint strategic needs assessments. Such an approach will also assist with ensuring that services are able to cater for changing trends in substance misuse (such as the increasing use of new psychoactive substances) as well as the complex mix of needs that some individuals experience. Moreover, this review demonstrates the importance of housing and employment in supporting recovery from substance misuse – another area in which probation staff can contribute. Progress has been made with addressing accommodation needs during the pandemic, and benefcial changes to practice in this area should be sustained. As well as ensuring that services are commissioned that are appropriate to need and accessible, it is important to ensure that people’s experience of accessing and working in these services is positive. Individuals may also be discouraged from accessing care by poor previous experiences, stigma and uncaring professional demeanour (Revolving Doors Agency, 2017; Sirdifeld et al., 2019), and Hearnden’s (2000) research on the role of probation and other interventions in reducing drug misuse highlighted that both staff and people under supervision felt that staff may beneft from additional training. A Capability Framework for Working effectively with people with co-occurring mental health and alcohol/drug use conditions has recently been published to support staff working in this area (Clinks, 2019). A small body of literature was identifed in the review which provided details of other potential models of provision that are not currently used in England and Wales. This included some evidence to suggest that where an intervention is provided can make a difference to outcomes. However, in some cases these papers

Substance misuse 47 were purely descriptive, and the heterogeneity in the remaining literature in terms of the samples used, type of intervention and outcomes measured means that it is very diffcult to recommend any one model as worthy of further exploration. It is clear that there are a number of challenges associated with conducting ‘realworld’ research in criminal justice settings, and that proper funding is needed to enable gaps in the literature to be addressed to support evidence-based commissioning in the future.

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Substance misuse 49 Her Majesty’s Prison and Probation Service & National Probation Service. (2019) National probation service health and social care strategy 2019–2022. London: National Probation Service. Hollway, T., Mawhinney, S., & Sheehy, N. (2007) Treating addiction, tackling crime: The impact of probation-led residential treatment on offender substance misuse, recidivism and attitudes towards the criminal justice system. Irish Probation Journal, 4(1): 108–124. Jason, L. A., Olson, B. D., & Harvey, R. (2015) Evaluating alternative aftercare models for ex-offenders. Journal of Drug Issues, 45(1): 53–68. https://doi.org /10.1177/0022042614552019 Joseph, H., Stancliff, S., & Langrod, J. (2000) Methadone maintenance treatment (MMT): A review of historical and clinical issues. Mount Sinai Journal of Medicine, 67(5&6): 347–363. Kelly, J. F., Finney, J. W., & Moos, R. (2005) Substance use disorder patients who are mandated to treatment: Characteristics, treatment process, and 1- and 5-year outcomes. Journal of Substance Abuse Treatment, 28(3): 213–223. https://doi .org/ 10.1016/j.jsat.2004.10.014 Kelly, S. M., O’Grady, K. E., Jaffe, J. H., Gandhi, D., & Schwartz, R. P. (2013) Improvements in outcomes in methadone patients on probation/parole regardless of counseling early in treatment. Journal of Addiction Medicine, 7(2): 133–138. Kelly, S. M., O’Grady, K. E., Mitchell, S. G., Brown, B. S., & Schwartz, R. P. (2011) Predictors of methadone treatment retention from a multi-site study: A survival analysis. Drug and Alcohol Dependence, 117: 170–175. Khanom, H., Samele, C., & Rutherford, M. (2009) A missed opportunity? Community sentences and the mental health treatment requirement. London: Centre for Mental Health. Kleinpeter, C., Deschenes, E. P., Blanks, J., Lepage, C. R., & Knox, M. (2006) Providing recovery services for offenders with co-occurring disorders. Journal of Dual Diagnosis, 3(1): 59–85. Kothari, G., Marsden, J., & Strang, J. (2002) Opportunities and obstacles for effective treatment of drug misusers in the criminal justice system in England and Wales. British Journal of Criminology, 42(2): 412–432. Longshore, D., Urada, D., Evans, E., Hser, Y.-I., Prendergast, M., & Hawken, A. (2005) Evaluation of the substance abuse and crime prevention act. Los Angeles, CA: University of California Los Angeles. Loue, S. (2003) The criminalization of the addictions: Toward a unifed approach. The Journal of Legal Medicine, 24(3): 281–330. Mackin, J., Carey, S. M., Finigan, M. W., Lucas, L. M., Strong, S. E., & Waller, M. S. (2008) Harford County district court adult drug court outcome and cost evaluation. Portland: NPC Research. Marchand, G., Waller, M., & Carey, S. M. (2006) Kalamazoo county adult drug treatment court outcome and cost evaluation. Final report. Portland: NPC Research. Martin, B. K., Clapp, L., Alfers, J., & Beresford, T. P. (2004) Adherence to courtordered disulfram at ffteen months: A naturalistic study. Journal of Substance Abuse Treatment, 26: 233–236. Martin, B. K., Clapp, L., Bialkowski, D., Bridgeford, D., Amponsah, A., Lyons, L., & Beresford, T. P. (2003) Compliance to supervised disulfram therapy: A comparison of voluntary and court-ordered patients. The American Journal on Addictions, 12(2): 137–143.

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Martyn, M. (2012) Drug and alcohol misuse among adult offenders on probation supervision: Findings from the drugs and alcohol survey 2011. Irish Probation Journal, 9: 75–93. McSweeney, T., Stevens, A., Hunt, N., & Turnbull, P. J. (2007) Twisting arms or a helping hand? Assessing the impact of ‘coerced’ and comparable ‘voluntary’ drug treatment options. British Journal of Criminology, 47: 470–490. Ministry of Justice. (2013) Transforming rehabilitation: A summary of evidence on reducing reoffending. London: Ministry of Justice. Ministry of Justice. (2020) A smarter approach to sentencing. London: Ministry of Justice. Murphy, D., & Sweet, A. (2004) Substance misuse and offending: An innovative partnership providing assessment and treatment. Irish Probation Journal, 1(1): 14–16. Nicosia, N., Kilmer, B., & Heaton, P. (2016) Can a criminal justice alcohol abstention programme with swift, certain, and modest sanctions (24/7 sobriety) reduce population mortality? A retrospective observational study. Lancet Psychiatry, 3: 226–232. https://doi.org/10.1016/S2215-0366(15)00416-2 Powell, C., Bankart, J., Christie, M., Bamber, D., & Arrindell, T. (2009) Drug testing in the criminal justice system: Solutions to a costly commodity. Journal of Substance Use, 14(6): 393–407. Public Health England. (2017) An evidence review of the outcomes that can be expected of drug misuse treatment in England. London: Public Health England. Public Health England. (2018) Continuity of care for adult prisoners with a substance misuse need. Report on the London ‘Deep dive’. London: Public Health England. Revolving Doors Agency. (2017) Rebalancing act. A resource for directors of public health, police and crime commissioners, the police service and other health and justice commissioners, service providers and users. London: Revolving Doors Agency. Sia, T. L., Dansereau, D. F., & Czuchry, M. L. (2000) Treatment readiness training and probationers' evaluation of substance abuse treatment in a criminal justice setting. Journal of Substance Abuse Treatment, 19: 459–467. https://doi.org/10 .1016/s0740- 5472(00)00139-2 Sirdifeld, C., Brooker, C., & Marples, R. (2020) Substance misuse and community supervision: A systematic review of the literature. Forensic Science International: Mind and Law, 1: 100031. Sirdifeld, C., Marples, R., Brooker, C., Denney, D., Siriwardena, N., MaxwellHarrison, D., Strachan, S., & Connell, T. (2019) Probation healthcare commissioning toolkit, a resource for commissioners and practitioners in health and criminal justice. Lincoln: University of Lincoln. Available from: www.probhct .blogs.lincoln.ac.uk Small, D. (2007) Fools rush in where angels fear to tread. Playing God with Vancouver's supervised injection facility in the political borderland. International Journal of Drug Policy, 18: 18–26. https://doi.org/10.1016/j.drugpo.2006.12 .013 Stageberg, P., Wilson, B., & Moore, R. G. (2001) Final report on the Polk County adult drug court. Des Moines, IA: Iowa Department of Human Rights. Turnbull, P. J., & Webster, R. (2007) Supervising crack-using offenders on drug treatment and testing orders. London: National Treatment Agency for Substance Misuse.

Substance misuse 51 Walters, S. T., Ondersma, S. J., Ingersoll, K. S., Rodriguez, M., Lerch, J., Rossheim, M. E., & Taxman, F. S. (2014) MAPIT: Development of a web-based intervention targeting substance abuse treatment in the criminal justice system. Journal of Substance Abuse Treatment, 46(1): 60–65. Winter, R. J., Young, J. T., Stoove, M., Agius, P. A., Hellard, M. E., & Kinner, S. A. (2016) Resumption of injecting drug use following release from prison in Australia. Drug and Alcohol Dependence, 168: 104–111. https://doi.org/10 .1016/ j.drugalcdep.2016.08.64

Part II

How common are mental health problems in probation?

5

The Lincolnshire prevalence study1 Charlie Brooker and Coral Sirdifeld

The overarching aim of this study was to pilot a methodology for assessing the prevalence of mental health disorder and substance misuse amongst people under probation supervision in Lincolnshire. This is an area in which existing literature and policy papers suggest there is a paucity of research. The study was divided into two main stages.

Stage 1 The frst stage investigated the prevalence of mental health disorder and substance misuse amongst people under probation supervision in Lincolnshire. It also examined participants’ self-reported needs, and the extent to which they felt that their needs were being met by existing service provision. A series of papers have been published from this study which report the prevalence of mental health disorders in probation (Brooker et al., 2012), the literature on prevalence of mental health disorders in probation (Sirdifeld, 2012), personality disorder in probation (Pluck et al., 2012), suicide and probation (Pluck and Brooker, 2014) and engaging service users in research (Sirdifeld et al., 2016).

Study design The screening measures employed When conducting this stage of the study, a number of established screening tools were used with a random sample of people under probation supervision that was stratifed by probation offce and tier of risk. Demographic information was collected about each participant. Two measures of substance misuse were included in the Stage 1 interviews to provide information on the extent of dual diagnosis in the sample. The Alcohol Use Disorders Identifcation Test (AUDIT) (Babor et al., 1992) contains ten items which are scored from 0 to 4 giving a total score ranging 1 This chapter is based on a study funded by the National Institute for Health Research (NIHR) Research for Patient Beneft Programme (Grant Reference Number PB-PG-0807-14022). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

DOI: 10.4324/9781003193456-7

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from 0 to 40. A score of 8+ indicates that it is very likely that the participant is drinking harmful levels of alcohol. This tool is cited as a ‘gold standard’ measure of levels of alcohol consumption (Newbury-Birch et al., 2009) and was selected for use in this study for several reasons. Firstly, this tool has previously been used in prison and court environments (6Farrell et al., 2002) and, at the time, was used by the National Probation Service to investigate levels of alcohol consumption. The Drug Abuse Screening Test short version (DAST) (Skinner, 1982) is a 20-item screen for drug abuse (including both use of illegal drugs and misuse of prescription drugs). A score of six or more indicates a substance misuse problem (abuse or dependence). Again, this tool was selected for inclusion in the study as it is quick and easy to administer and has been shown to be reliable and to have good levels of sensitivity and specifcity when used with criminal justice populations. Skinner (1982) showed that the scale has high internal consistency reliability, and Maly (1993) showed that DAST has a sensitivity of 96% and a specifcity of 79–81% (McPherson and Hersch, 2000). The Standardised Assessment of Personality – Abbreviated Scale (SAPAS) is a brief eight-item screening for likely cases of personality disorder, which was validated by Moran et al. (2003). This tool was selected for use in the study for a number of reasons. Firstly, it is brief to administer and does not require specialist training to use, meaning that it may be suitable for use by probation staff as part of their everyday practice. Secondly, Moran et al. (2003) state that this tool performs well in settings where you would expect the prevalence of personality disorder to be high, suggesting that it is likely to be appropriate for use in probation settings. A sub-study of this project was designed to compare results of screening using SAPAS with a sub-sample of 40 cases who completed the ‘gold standard’ for personality disorder screening (the SCID-II) and has been reported (Pluck et al., 2012). PriSnQuest is an eight-item questionnaire which was designed specifcally for use as a brief screening instrument in prisons to determine whether someone is likely to have a serious mental illness. Individuals who score 3+ are said to have symptoms of mental illness requiring investigation by a suitably qualifed professional. Two additional questions were added to this tool – ‘Have you ever seen anyone formally in any kind of mental health service?’ and ‘Have you ever previously been diagnosed with a mental health disorder?’ In order to be over-inclusive, participants who scored 3+ on the PriSnQuest or answered ‘yes’ to the frst of the two additional questions were asked to continue onto the later stages of the questionnaire. Those who did not meet these criteria were not asked any additional questions. The Mini International Neuropsychiatric Interview (MINI) is a short diagnostic interview which screens for a combination of current and lifetime DSM-IV and ICD-10 mental health disorders. This tool was selected for inclusion in the study as it has a relatively short administration time (meaning that it is suitable for use with individuals with short attention spans and/or appointments with multiple agencies, and making it more likely that it could be used by probation staff as part of their everyday activities). In addition, it has been used in a number of studies in criminal justice settings (see, for example, Marzano et al., 2010; Black et al., 2004; Lurigio et al., 2003).

The Lincolnshire prevalence study 57 The Camberwell Assessment of Needs (CANFOR) was developed by PriSM at the Institute of Psychiatry to assess the needs of individuals with severe mental illness (Phelan et al., 1995). The short version of this tool (CANFOR-S) was included in the study and investigates a range of 25 areas in which people may have diffculties, whether people are receiving help in these areas and whether they are satisfed with any help that they are receiving or perceive the area to still be a problem for them. The focus of this tool is on the month prior to the interview. This tool was included in the study as a means of investigating self-reported ‘needs’. In addition, it was used to investigate the extent to which participants were receiving what they perceived to be ‘adequate support’ in areas in which they identifed that they had a need. Finally, an amended version of the Client Socio-demographic and Service Receipt Inventory – European Version (CSSRI-EU) (Beecham and Knapp, 1992) was used to investigate patterns of service access. This tool was amended to avoid repetition of questions covered elsewhere in the interview; we focused in particular on the ‘service receipt’ and ‘medication profle’ sections of this tool.

Analysis procedures Data were entered into SPSS version 14 and summarised using descriptive statistics. Percentages were rounded to one decimal place. Further weighted analysis required that the data be transferred to STATA version 10. This allowed the analysis to take account of the false negative (i.e., hidden) cases by using weights for the cases detected amongst the original PriSnQuest screened negatives (Dunn et al., 1999). The revised estimates and associated confdence intervals are estimated using the STATA logit procedure with probability weights. In order to assess the association between potential risk factors and current disorder, weighted logistic regression was used. In the frst place, each variable was assessed separately; any association with a signifcance level of less than 10% was then entered into a further multivariate analysis restricted by domain (i.e., demographic, crime-related and clinical). Finally, using the same criteria (p < 0.10) from the previous analysis, the remaining variables were entered into a fnal model.

Findings Sample characteristics Comparison of the individuals within the study sample to those on the overall caseload for Lincolnshire Probation Trust reveals very little difference between the two groups in terms of gender and ethnicity; 87% of both groups are male, 13% female and approximately 2% of both samples are black and ethnic minority, whilst the remainder are white. In terms of tier of risk, those in tier one were slightly under-represented in the study sample (9% compared to 18% in the overall caseload), and those in tier

58 Charlie Brooker and Coral Sirdifeld three were slightly over-represented (50% compared to 42%). Further examination of the sample characteristics shows that the study participants had a mean age of 36 years, and a median age of 33 years. In 2009 the overall employment rate in Lincolnshire was 73.1%, and 11% of the working age population in Lincolnshire had no qualifcations (LRO, 2011). However, 60.7% of the study sample were unemployed, with just 26.6% classing themselves as in paid employment or selfemployed, and 32.9% had no qualifcations – demonstrating that offenders have a higher level of deprivation than that of the general population.

Prevalence People under probation supervision were found to be a deprived group, with a high prevalence of mental illness when compared to the general population. Overall, 39% of participants had a current mental illness and 49% of participants had a past/lifetime disorder. Key results in terms of particular diagnostic categories were as follows: ● ● ● ● ●

● ●

18% of participants had a current mood disorder 27% of participants had a current anxiety disorder 11% of participants had a current psychotic disorder 5% of participants had a current eating disorder 47.4% of participants were ‘likely cases’ of personality disorder according to the SAPAS 44% of participants had a past/lifetime mood disorder 18.5% of participants had a past/lifetime psychotic disorder

When looking at levels of substance misuse amongst people under probation supervision, results show that 55.5% of participants scored 8+ on AUDIT, indicating a strong likelihood of hazardous/harmful alcohol consumption, and 12.1% of participants scored 11+ on DAST, indicating ‘substantial’ or ‘severe’ levels of drug use. A weighted logistic regression analysis suggested that the following variables were associated with an increased risk of a current mental illness at a statistically signifcant level: receiving benefts, suicidality and personality disorder. In addition, the following were associated with a reduced risk of a current mental illness at a statistically signifcant level: increasing age and paid employment. However, only ‘age’ retained a statistically signifcant association in the presence of other variables in the fnal model. The lack of other signifcant associations is likely to be due to the sample size in the study (Table 5.1).

Co-morbidity and dual diagnosis Levels of co-morbidity and dual diagnosis are known to be high in prison populations, but very little research has examined this in a probation population. Results of this study suggest that there is also a very high degree of co-morbidity and dual diagnosis in a probation population.

The Lincolnshire prevalence study 59 Table 5.1 Results of Covariate Analyses Using Weighted Logistic Regression. Main Outcome, Any Current Disorder Variable (domain)

Demographic Male sex Age (years) Married Education (GCSE+) Owner occupier Employment Claim beneft Urban Crime-related Previous prison Violence to person Clinical Alcohol problem Drug problem Suicidality (three levels) Personality disorder

Univariate odds ratio (95% CI)*

Domain-specifc Full multivariate multivariate odds odds ratio (95% ratio (95% CI)** CI)***

2.01 (0.47, 8.61) 0.94 (0.91, 0.98) 0.95 (0.91, 0.99) 0.95 (0.91, 0.99) 0.34 (0.09, 1.34) 1.40 (0.47, 4.14) 0.37 (0.10, 1.37) 0.20 (0.06, 0.62) 0.26 (0.06, 1.04) 0.32 (0.09, 1.20) 3.54 (1.09, 11.55) 0.93 (0.21, 4.10) 0.85 (0.29, 2.46) 1.09 (0.38, 3.18) 1.61 (0.57, 4.56) 2.05 (0.74, 5.74) 2.77 (0.66, 11.67) 3.22 (1.60, 6.53) 2.60 (1.20, 5.66) 2.24 (0.91, 5.48) 3.88 (1.17, 12.84) 3.09 (0.91, 10.51) 2.59 (0.73, 9.16)

*Entered singularly. **Selected if p < 0.10 within domain. ***Selected if p < 0.10 from domain analysis.

Of those who were positive on the PriSnQuest screen, 72.3% had both a substance misuse problem and a current mental illness. Levels of dual diagnosis were higher for use of alcohol than for use of drugs. Furthermore, 89.4% of participants with a current mental illness also had a personality disorder (Table 5.2).

Table 5.2 Prevalence of Current Major Disorders and Likely Personality Disorder Disorder

Likely personality disorder CI (95%) (%) (SAPAS% score of 3+)

Any current mood disorder (n = 26) Any current anxiety disorder (n = 37) Any current psychotic disorder (n = 14) Any current eating disorder (n = 4) Any current mental illness (n = 47) No current mental illness (n = 41)

23 34 11 4 42 15

88.5 91.9 78.6 100.0 89.4 36.6

* This table is only based on those (n = 88) who were PriSnQuest positive.

76.2–100.0 83.1–100.0 57.1–100.0 100.0–100.0 80.6–98.2 21.8–51.3

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Self-assessed needs The results of the CANFOR-S screening tool indicated that participants with a current mental illness had a higher mean level of need than those without (mean scores were 10.53 and 4.59 respectively). Results of a Mann–Whitney ‘U’ test also showed that there was a statistically signifcant difference between these two groups in terms of their mean ‘met’ and ‘unmet’ needs scores at the p =