Offenders with complex needs literature review

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Literature Review Offenders with Complex Needs:

Substance Misuse, Mental Health Problems & Learning Disability

v2.4 10th June 2014 S. Senker & M. Scott Draft

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Literature Review

Offenders with Complex Needs: Substance Misuse, Mental Health Problems & Learning Disability

EXECUTIVE SUMMARY 3

1. INTRODUCTION 5 1.1 Methods 5

2. DEFINITION 6 2.1 The problem with definition 6

3. PREVALENCE 7 3.1 Identifying and estimating prevalence 7

4. IDENTIFICATION 9 4.1 The tools of identification 9

5. RELATIONSHIP WITH OFFENDING 11 5.1 Substance misuse, learning disability, mental illness and offending 11

6. SERVICE USER PERSPECTIVES 13 6.1 The experience & perception of the criminal justice system by offenders with complex needs 13

7. IMPROVEMENTS 14 7.1 Recommendations for best practice – areas for improvement 14

8. WHAT WORKS 16 8.1 The existence of modified programmes for offenders with complex needs 16

9. CONCLUSIONS & CONSIDERATIONS 18

REFERENCES 20

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EXECUTIVE SUMMARY INTERLINKED RELATIONSHIPS There is a strong and recognised relationship between Substance Misuse (SM), Mental Health problems (MH), Learning Disability (LD) and offending in terms of:

• An increased likelihood of committing a range of crimes from acquisitive offences (drug misuse); violent crime (alcohol and MH), sex offences and arson (LD)and re-‐offending (drug users are 3-‐4 times more likely to commit crime than non-‐users)

• Their prevalence in offending populations (an estimated 25% -‐ 65% of offenders have MH, 50% SM and 30% LD needs)

• Their prevalent, overlapping, co-‐occurring in nature (dual diagnosis is the norm not the exception and 60% of individuals with LD will also have an SM problem)

These issues, therefore, have a high cost to the criminal justice system (estimated at £13.9 billion for drug related crime). Individuals in the criminal justice system present with a variety and multiplicity of needs. Offenders with these needs are often more vulnerable in the criminal justice system (CJS) – being more likely to experience restraint in custody (LD & MH), violence (alcohol), being frightened and confused (MH/LD) with higher rates of attempted suicide and self harm (LD). They are also more vulnerable on exit from the Criminal Justice System, experiencing higher rates of housing difficulty and unemployment. Research and campaigning organisations have made strong and enduring calls for dual diagnosis services (SM/MH) & MH/LD services to be delivered jointly for offenders. These groups have unequal access to support options available to other offenders, and are then further disadvantaged. IDENTIFICATION IS VITAL Identification of these needs for offenders should be at the earliest possible point in the CJS, and also repeated on entry to prison and probation. This is crucial when rehabilitating people to reduce re-‐offending, not least with regard to making appropriate referrals and recommendations for their adapting sentences or facilitating access to suitable treatment. Due to a number of factors, there is chronic underreporting of these issues for offenders:

• There is great variation in the criteria and terminology used to identify these needs across agencies and across the country

• The data not regularly or uniformally captured (e.g. sometimes only a “primary” factor can be recorded)

• Individuals fear being stigmatised and do not divulge information, meaning that identification must be sensitively handled

• There is a lack of consistent, validated tools – with many of those in circulation requiring specialist skills or training and/or significant time to complete them

• Practitioners do not feel skilled or empowered to identify these needs

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GAPS IN CAPACITY & CAPABILITY The literature identifies a number of key gaps in capacity and capability to identify and respond to these issues:

• Staff skills & awareness – training needs have been highlighted around identification, how to adapt and deliver programmes, and delivery of specific interventions, or to treat multiple overlapping needs

• Service provision – some unmet need, divisions between services, no unified services across these issues, all contributing to a disparate & siloed approach

ADAPTING REHABILITATION Evidence shows that some adapted programmes, use of appropriate sentencing and ensuring access to specific support or treatment based on these needs can improve the efficacy of rehabilitation and preventing re-‐offending among offenders with complex needs. Drug treatment can decrease reconviction rates by 47%, and early treatment of mental health problems is preventative for violent crime. These findings are in line with the Risk, Need, Responsivity (RNR) Principles used to adapt rehabilitation programmes by targeting criminogenic needs. Government guidance and calls from campaigning organisations agree that a “Care not Custody” approach may be more effective in rehabilitating offenders with these presenting issues. Specific issue treatment programmes have an impact on reducing re-‐offending. The best evidence is for drug treatment (£2.50 is realised on savings to society in terms of criminal and health economies for every £1 invested in treatment). However more research is required to evidence the impact of specialised interventions on recidivism rates for those experiencing problems with alcohol, MH or LD. RECOMMENDATIONS TO CONSIDER The literature points to a number of recommendations that have been regularly made to help deal with these issues more effectively:

• Introduce an integrated service throughout the CJS process and unified across MH, LD, SM agencies

• Terminology and criteria used to identify these needs should be specific and consistently applied

• Tools used to aid identification should be validated, comprehensive and used at the earliest opportunity and throughout the CJS

• Practitioners should feel skilled, confident and competent at identification of these needs and ensuing adaptation and referral

• Agencies and policy makers should consult CJS service users in improving the response to these needs

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1. INTRODUCTION Individuals in the criminal justice system present with a variety and multiplicity of needs. Identifying

these needs are crucial when rehabilitating people to reduce re-‐offending, not least with regard to

making appropriate referrals and recommendations for their treatment.

This literature review will attend to the definitions of substance misuse, mental health problems and

learning disability, their prevalence within the criminal justice domain, the tools available and

utilised for their identification, and the way current treatment programmes have been adapted to

cater for these needs. In addition previous recommendations will be considered as well as literature

giving a voice to those in the criminal justice system about their experiences.

1.1 Methods Attending to the structure of the literature review was an imperative first step to ensure that all

three of the needs (learning disability, mental health problems, substance misuse) were considered

under each subheading. Broad computer based searches of Google Scholar, PSYCHinfo, Science

Direct and MEDLINE were undertaken utilising search terms which co-‐located offending and complex

needs: “offenders with learning disability”, “offenders with mental illness”, “offending and

substance misuse”. This helped identify some of the dominant journals such as; British Journal of

Learning Disabilities, Journal of Intellectual Disability Research, Journal of Intellectual and

Developmental Disability, Journal of Substance Use and Misuse; Journal of Substance Use

Treatment; Criminal Behaviour and Mental Health, Journal of Forensic Psychology and Psychiatry.

Individual search terms were entered into these journals according to the section being written e.g.

“prevalence of offenders with mental health problems”; “service users’ perceptions”;

“modified/adapted treatment for offenders with learning disability”. Where papers could not be

accessed, the author was emailed directly (e.g. Professor Rose at the University of Birmingham).

Once a valuable article was found, citing articles were checked as well as the reference section of

each paper. This often led to other useful articles. Government papers were also consulted as well as

statistics from the Office of National Statistics and Ministry of Justice.

Priority was given to UK research in order to give an accurate representation of the current scope of

the problem, this was particularly important for prevalence figures but remained at the forefront of

considerations throughout. Most recent investigations were also privileged, again to provide up to

date, relevant information. It should be noted, that much of the cited research comes from the

prison estate. A lack of academic literature considered probation and custody settings although this

has been investigated recently by a join inspectorate commission for offenders with learning

disabilities. A paucity of research into mentally disordered offenders on probation has been

observed and noted elsewhere (Brooker, Denney, Sirdifield, 2014).

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2. DEFINITION

2.1 The problem with definition Defining the concepts of substance misuse, learning disability and mental illness has been noted as

an area of difficulty (Bradley, 2009). Therefore it is important to consider the way in which these

three ‘needs’ have been defined elsewhere, as well as the ‘standard’ definitions and notations

utilised in research.

Firstly, substance misuse is defined and discussed clinically by the Diagnostic and Statistical Manual

of Mental Disorders (DSM). Such a tool has most recently proposed that an individual can be

classified as having substance use disorder, as well as a specific opioid use disorder1, if they meet

two or more criteria within a 12 month period. These include factors such as a failure to fulfil major

role obligations, continued use despite persistent social or interpersonal problems caused or

worsened by the substance, tolerance and withdrawal effects, persistent unsuccessful efforts to cut

down or control substance use and a great deal of time invested in obtaining, using or recovering

from the substance (American Psychiatric Association, 2012). The latest version of the DSM, DSM-‐IV,

deliberately combines abuse and dependence following high correlation in factor analysis studies

(Grant et al., 2007). It also paints a picture of substance use disorder being all consuming, affecting

vast domains of an individual’s life.

With regards to learning disability, it has been noted that most UK studies utilise a strict criteria such

as an IQ measure of 70 or below in order to diagnose someone as having a learning disability

(Loucks, 2007). However, this can be misleading and should not be used as the only qualifying

criteria as it fails to consider social functioning (Craig, Stringer & Moss, 2006; DoH, 2001). Bradley

(2009) defines a learning disability as having the following three qualities:

(i) a significantly reduced ability to understand new or complex information,

(ii) to learn new skills (impaired intelligence),

(iii) with a reduced ability to cope independently (impaired social functioning) which started

before adulthood, with a lasting effect on development.

In contrast, the term learning difficulty is a more inclusive term and pertains to a wider spectrum of

disorders such as dyslexia and those on the autistic spectrum. The differences in the scope of these

definitions clearly prove problematic when trying to ascertain prevalence, as some studies or

services may not necessarily specify the ‘threshold’ or definition being used to diagnose someone as

having a learning deficit (e.g. whether they are using disability or difficulty).

1 Substance/Opioid Use Disorder is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress (APA, 2012).

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Finally, with regards to the definition of mental illness, Bradley (2009) acknowledges the diversity in

definition from mentally disordered offender (where the mental health problem has a demonstrable

link to the offence) to mental disturbance which does not warrant diagnosis as outlined by the

Mental Health Act (2007) but still causes problems and difficulties for the individual. Terms such as

mental health, mental illness or mental disorder may be used interchangeably and can be

misleading. Mental health can be used to indicate the absence of any mental health problem,

mental illness can refer to presenting symptoms and difficulties, where mental disorder indicates a

clinical diagnosis and meeting of specified criteria. The National Institute for Health and Care

Excellence (NICE) considers depression, generalised anxiety, panic disorder, obsessive compulsive

disorder and post-‐traumatic stress disorder to be common mental health disorders. Meeting the

criteria featured in the DSM deciphers whether a mental health problem is classified as a ‘disorder’.

Prevalence statistics may include any range of dysfunctions or impairments (from identified

problems and difficulties, to clinical diagnoses). The variety in scope makes it difficult to make

comparisons across studies (Forrester et al., 2013). It is important to be mindful of these differing

definitions and criteria in light of the review below, and many research studies offer caveats that

acknowledge the risk of overestimation or underestimation (e.g. Hassiotis et al, 2011).

3. PREVALENCE

3.1 Identifying and estimating prevalence It has been estimated that approximately 30% of offenders in prison have a learning difficulty

characterised by an IQ of 79 or below, a figure replicated in national and local studies (Bradley, 2009;

Hayes, Shackell, Mottram & Lancaster, 2007). This figure may be even higher in female offending

populations (up to 40%; Mottram & Lancaster, 2006). Although this represents a significant

proportion of individuals across the criminal justice system, the idea that offenders with learning

disabilities and difficulties are a ‘forgotten’ population has been noted by the Prison Reform Trust in

their ‘No-‐One Knows’ programme (Talbot, 2008). Estimates on the proportion of offenders with

mental health difficulties show considerable range. For example, Senior et al. (2013) estimated that

23% 2 of the prison population had a severe mental health problem and acknowledged that prison

in-‐reach teams do not work with all those identified. For offenders in the community; an

interrogation of probation data at one UK trust yielded a prevalence rate of 27% of offenders with

current mental illness (Brooker et al., 2012). Almost 4,000 offenders were detained under the

Mental Health Act in hospital at the end of 2008. A significant proportion of these were transferred

to hospital from HM Prison Service following sentencing (MoJ, 2010). Whilst these findings attend to

2 This UK study defined mental health as a ‘severe and enduring mental illness’ as utilised by community mental health teams. This may account for the differential figure compared to studies who use a more generalised mental health problem as their source of classification.

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more severe mental health problems, previous data considering 11 different diagnoses from

psychosis and personality disorder to more mild symptoms and presentations such as sleep

difficulties and worries, indicates 33% of male offenders in custody suffered from depression (this

was higher for women and those on remand) and 64% of sentenced male offenders had a

personality disorder (Singleton, Meltzer, Gatward, 1998). Women are consistently shown to have a

higher prevalence of mental illness in offending samples alongside higher rates of self harm and

suicide. Women prisoners account for 30% of all incidents of self-‐harm despite representing just 5%

of the total prison population. In addition, 46% of women prisoners reported having attempted

suicide at some point in their lives. This is more than twice the rate of male prisoners (21%) and

higher than in the general UK population amongst whom around 6% report having ever attempted

suicide (Ministry of Justice, 2013).

Furthermore over 50% of the prison population admits to using at least one drug in the year before

coming to prison (32% of sentenced men noted severe dependence before entering prison) and 48%

of sentenced male prisoners admitted to using drugs during their sentence (Singleton, Farrell &

Meltzer, 2003). Female prisoners report more Class A drug use in the four weeks before custody

than male prisoners, and were also more likely to report that their offending was to support

someone else’s (as well as their own) drug use (Ministry of Justice, 2013). Dual diagnosis is well

established with substance misuse recognised as the most common co-‐morbid disorder to occur

with severe mental illness (Drake, et al. 2001). In one national sample of offenders, dependence on

opiates or stimulants increased the likelihood of having a personality disorder by six times (Singleton

et al., 2003). In his review of prison drug treatment, Lord Patel noted that dual diagnosis should be

considered the norm rather than the exception (2010).

Additionally, a correlation between learning difficulties and substance misuse is also emerging, with

60% of individuals with learning difficulties estimated to have a substance misuse problem (Crocker

et al., 2007a). Overall, whilst it can be seen that offenders with either a learning difficulty, substance

misuse problem or mental health problem are highly prevalent, notwithstanding the difficulty in

definition, there is also an acknowledgment that the co-‐occurrence of such problems is

overrepresented in the criminal justice system (Osher, 2008). There is a need to replicate the large-‐

scale investigation of the psychiatric morbidity in prisoners as conducted by Singleton et al., (1998)

with a view to including learning disability and attending to other points in the criminal justice

journey (Bradley, 2009).

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4. IDENTIFICATION

4.1 The tools of identification Identifying individuals with complex needs is vital to the next steps in their treatment and

management (Bradley, 2009). This said, identification is often the first stumbling block in the process

of working with offenders with complex needs and presents a barrier to the provision of accurate

prevalence rates as well as adequate and appropriate treatment.

Identifying offenders with mental health disorders is usually undertaken by health care professionals

using strict diagnostic criteria as set out by the DSM. This is useful if an offender’s mental health

meets the threshold for formal diagnosis, but may be less helpful if offenders are suffering from

mental health problems such as depression that do not meet clinical criteria. Where this occurs,

referrals to services other than in-‐reach teams may be appropriate.

With regards to substance misuse identification, this is often through self-‐report and criminal justice

agencies use a range of screening tools. Although self-‐report data has been queried in the past,

comparisons with biomarkers, qualitative interviews and criminal records show it is a reliable

method for identifying drug and alcohol use (Darke, 1998).

The Treatment Outcome Profile (TOP; Marsden et al., 2008) represents a reliable and valid tool for

measuring outcomes of treatment and feeds into National Drug Treatment Monitoring System

(NDTMS) data. There are four domains that form its focus; substance use, health, crime and social

functioning, reflective of the holistic evaluation of treatment, moving beyond drug use. Although

this has also traditionally remained in the community environment, local councils in Essex are

piloting its suitability within the prison domain to further ensure seamless information sharing. Use

of the Drug Abuse Screen Test (DAST; Skinner, 1982) has also been incorporated when identifying

drug misuse in police custody (McGilloway & Donnelly, 2004) and this has been correlated with the

DSM diagnosis of substance dependence (Gavin, Ross & Skinner, 1989).

The Alcohol Use Disorder Identification Test (AUDIT) developed by the World Health Organisation

has been utilised in offender samples also. MacAskill et al., (2012) found that the AUDIT could be

utilised and administered by trained prison officers to identify needs in new admissions to prison.

More recently, the AUDIT has been found to have good predictive validity of drinking behaviour

following release of offenders from prison (Thomas, Degenhardt, Alati & Kinner, 2014). The

shortened version, the AUDIT C is also used by third sector drug and alcohol organisations in Essex

who may work with offender samples. Scores on the AUDIT are able to identify the level and nature

of drinking (assessing for dependency) and as such, inform health care providers about the tier and

level of treatment that is appropriate for that offender.

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Identifying offenders with learning disabilities is more complex and the prevalence of such

individuals may be underestimated. Learning disability services may not be aware of, or under-‐

report, criminal activity. Similarly individuals already in the criminal justice system may be less

inclined to admit to having these difficulties for fear of bullying or victimisation (Loucks, 2007). With

regards to tools for identification, learning disability can be identified using validated psychometric

measures such as the Wechsler Adult Intelligence Scale (WAIS-‐IV; Wechsler, 2008). Whilst such a

tool considers multiple elements of functioning and gives a full scale IQ measure, it is lengthy to

administer, requires specialist skills and training and therefore may only be appropriate if an

offender is already suspected of having an intellectual impairment rather than being conducted

routinely at different entry points within the criminal justice system.

The abbreviated version, the Wechsler Adult Abbreviated Scale of Intelligence (WASI; Wechsler,

1999) can overcome some of the difficulties of duration of assessment but as a result is not a

comprehensive tool and has been criticised for its inability to distinguish between specific learning

disabilities. Although the Wechsler scales have been used within forensic populations (e.g. Langevin

& Curnoe, 2008), the fact they can only be administered by a professional trained in this proficiency

limits their ability to be used on a national and regular scale, e.g. routinely on entry to prison or

police custody. The Learning Disability Screening Questionnaire (LDSQ; McKenzie & Paxton, 2006)

overcomes this problem as it can be administered by someone who knows the recipient well or

indeed by individuals themselves. This level of flexibility is advantageous in criminal justice settings.

The validity of the LDSQ has recently been assessed in forensic settings and populations and has

received favourable review demonstrating specificity, sensitivity and discriminative validity

(McKenzie, Michie, Murray & Hales, 2012).

This said, specificity was found to be lower in forensic populations than general samples, which

indicates a risk of this tool not reliably identifying an individual with a learning disability. Further

research is required to consider the extension of the LDSQ to a wider sample and increase certainty

in its utility in forensic settings although these initial results are promising. Other available tools

include the Learning Disabilities in the Probation Service scale (LIPS; Mason & Murphy, 2002) which

has been utilised in community samples (Mason & Murphy, 2002b) and the Hayes Ability Screening

Index (HASI; Hayes, 2000). As intellectual disability extends beyond IQ scores, the Vineland Adaptive

Behaviour Scales can assess adaptive functioning (Sparrow, Bella & Cicchetti, 1984) useful for

treatment decisions in offending cohorts (Keeling, Beech & Rose, 2007). Whilst these tools exist

however, there is not a consensus or routine application of these across different criminal justice

settings.

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5. RELATIONSHIP WITH OFFENDING

5.1 Substance misuse, learning disability, mental illness and offending Although learning disability, mental illness and substance misuse occur frequently in the offending

population, it is also important to consider the impact such needs have on one’s behaviour and

whether this contributes to recidivism.

Drug users have been noted to be three to four times more likely to commit crime than non-‐drug

users (Bennett, Holloway & Farrington, 2008), with heroin and crack users particularly responsible

for a disproportionate amount of acquisitive crime (e.g. theft, burglary, robbery) (Bukten et al.,

2011; Makkai, 2001; McIntosh, Bloor & Robertson, 2007). This highlights the need for the treatment

and rehabilitation of substance misusing offenders. The National Treatment Agency (NTA) estimates

that for every substance misusing offender not in treatment, this costs society £26,074 per year

based on the number of offences likely to be committed (NTA, 2012). Similarly they estimated that

drug treatment prevented an estimated 4.9 million crimes in 2010-‐2011 not least because of the

impact drug treatment is said to have on reconviction rates (up to 47% decrease, NTA, 2012b).

Alcohol too has historically been linked with an increased risk of offending ranging from antisocial

behaviour, violence and homicide (Bellis, Hughes & Hughes, 2005). In addition, consumption of

alcohol has been noted to make individuals more vulnerable to becoming a victim and a perpetrator

of interpersonal violence (Abramsky et al., 2011). The legality of alcohol means its impact is far-‐

reaching and prevalent – individuals who engaged in ‘pre-‐drinking’ before a night out were 2.5 times

more likely to be involved in a fight (Hughes, Anderson Morleo & Bellis, 2008). Whilst these

altercations may not have resulted in a criminal conviction, there are clear societal and economic

implications.

Considering offending and mental health, schizophrenia (Fazel, Gulati, Linsell, Geddes & Grann,

2009) as well as psychosis (Douglas, Guy & Hart, 2009) has been linked to an increased risk of

violence to others. This risk is increased further where substance misuse is an issue, with researchers

once again heralding the treatment of substance misuse as an all important factor in reducing

offending in this population (Fazel et al., 2009; Walsh, Buchanan & Fahy, 2002). As such, although

the link between mental health and offending is noteworthy, it is also important to acknowledge

that the proportion of violent crime in society as a whole attributable to those with schizophrenia is

less than 10% (Walsh et al., 2002). Risk of homicide in psychosis is considerably lessened after

treatment which again highlights the need for early identification and intervention (Nielssen &

Large, 2010).

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Turning to the link between learning disability and offending, a prospective study in the UK found

that sexual offending and arson were over-‐represented in a cohort of intellectually disabled

offenders3 , violent offences were more prevalent amongst these individuals and offending began at

an earlier age (Barron, Hassiotis and Banes, 2004). Arson has been noted as an offence particularly

correlated with learning disability elsewhere (e.g. Alexander, Piachaud, Odebiyi & Gangadharan,

2002) perhaps because of its association with limited interpersonal contact that offenders with

learning disabilities may be keen to avoid. In addition, learning disability and sexual aggression has

also been linked through poor social and interpersonal skills (Craig et al., 2006), poor impulse control

and a lack of understanding about the illegality of sexual offending (Keeling & Rose, 2012). As such,

although there is a high prevalence of sexual offending within learning disabled offender cohorts,

this may not be due to deviant sexual preferences (Camilleri & Quinsey, 2011). Furthermore, due to

their validation with non-‐learning disabled populations, traditional risk assessments such as the

Rapid Risk Assessment for Sexual Recidivism (RRASOR; Hanson, 1997) have been difficult to apply to

learning disabled cohorts which mean ascertaining an accurate prediction of risk is problematic

(Hanson, Sheahan & VanZuylen, 2013).

Attending to co-‐occurrence of disorders and offending, a link between substance misuse, learning

difficulty and offending behaviour is becoming more established (McGillivray & Moore, 2001;

Murphy & Mason, 2014). Individuals with learning difficulties and severe mental health problems

have also been shown to be more likely to demonstrate violence and be arrested (Crocker, Mercier,

Allaire & Roy, 2007) and offenders with intellectual disability have been seen to have more

prevalence of probable psychosis (Hassiotis et al., 2011).

Such evidence highlights the urgency in considering offenders with complex needs, particularly with

regards to minimising risk to the public and further offending behaviour.

3 This study utilised the definition of an IQ under 80 and considered offending to mean any contact with the criminal justice system, even if this was just police arrest without conviction.

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6. SERVICE USER PERSPECTIVES

6.1 The experience and perception of the criminal justice system by offenders with complex needs Substance misusing offenders report a level of stigma projected towards them from wider society,

other offenders and other drug users (Rhodes et al., 2007; Rødner, 2005; Simpson, 2003). As a

result, substance misusing offenders assimilate a pronounced level of shame and guilt which can

often propel further use. Isolated recovery wings in prison settings can shield individuals from such

stigma in the sense they are located with other users, however they may still be subject to prejudice

and stigma from the general population within the prison. Prisoners have reported however that

they prefer a segregated drug recovery wing especially when queuing to collect their substitute

prescriptions (Senker, unpublished).

The experience of the criminal justice system and process extends beyond prison. Post release has

been highlighted as a particular time of difficulty and vulnerability for offenders with mental health

problems (Binswanger et al., 2011). Furthermore, offenders in forensic hospitals articulated that

stigma was felt more acutely due to the duality of being an offender and having a mental health

difficulty, which was problematic for recovery efforts (Mezey et al., 2010). For prisoners with mental

health problems, there is a subjective perception of needs being unmet, in particular; a lack of

daytime activities and resolution of psychotic symptoms or psychological distress (Harty, Jarrett,

Thornicroft & Shaw, 2012). The number of perceived unmet needs is greater in offenders on health

care wings in prisons than offenders in secure hospitals and mentally unwell offenders in prison

report higher levels of dissatisfaction with services (Thomas, 2005).

Prisoners with learning disabilities are more likely to report a lack of social support and have a higher

frequency of attempted suicide and self-‐harm (Hassiotis et al., 2011). Learning disabled prisoners

found it hard to make themselves understood, were more likely to have been restrained and missed

out on elements of the prison regime such as visits and gym attendance due to lack of understanding

about the process or difficulties completing requests. This may be misinterpreted as ‘bad’ or

disruptive behaviour by prison staff (Talbot, 2008). Much of the challenges described in prison may

be related to a lack of desire to highlight difficulty in understanding for fear of bullying or

victimisation (Loucks, 2007). Individuals with learning disabilities admitted to psychiatric wards

reported feeling vulnerable and scared upon admission with a lack of understanding about why they

need to take medication, as such an integrated facility was advocated whereby beds for learning

disabled individuals were allocated within the psychiatric unit (Parkes, Samuels, Hassiotis, Lynggard

& Hall, 2007). Furthermore, individuals with a mild learning disability report a sense of

powerlessness and confusion as to whether they were being cared for or punished when detained

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under the Mental Health Act (McNally, Beail & Kellett, 2007). It is important to note experiences of

those in secure units are not wholly negative (Carlin, Gudjonsson & Yates, 2005).

Although the cited research is not specifically with offenders, the correlation between mental

health, learning disability and offending means some individuals may have committed offences and

not been charged or convicted. This research also consolidated the importance of seeking the

opinions and experiences of service users when developing services, a sentiment echoed elsewhere

in provisions for individuals with psychosis and learning disabilities (Hemmings, Underwood &

Bouras, 2009). Despite this, the literature in the field of service user perspectives in forensic mental

health has been noted as limited (Coffey, 2006).

7. IMPROVEMENTS

7.1 Recommendations for best practice – areas for improvement The importance of identifying offenders with complex needs cannot be minimised and has been

highlighted by several Government papers in recent times (e.g. Bradley, 2009; Corston, 2007; Patel,

2010; Home Office, 2001).

In his evaluation on drug treatment in prison and upon release, Lord Patel (2010) made several

recommendations about the future of supporting substance misusing offenders. These included:

• Individualised treatment plans offering intervention to the right person at the right time and

in the right way

• Integrated pathways between prison and community

• A focus on reintegration and resettlement

• A recovery paradigm with service users at the very heart of it.

Considering treatment for offenders with mental health problems, despite the frequency of dual

diagnosis, services rarely cater for individuals presenting with both issues4, resulting in a disparate,

unintegrated system which may be difficult for individuals to navigate. This has prompted calls for

an integrated, unified service which can cater for and treat both problems simultaneously under

one roof (Bradley, 2009; Brooker et al., 2014; Drake et al., 2001). Innovations in US practice have

seen specialised probation officers trained to supervise offenders with mental health problems,

although this has not been replicated yet in the UK (Brooker et al., 2014).

Furthermore, although mental health in-‐reach teams in prison were a promising and welcome

addition to the criminal justice system and represented a merging between punishment and health,

there remains a need for diversion and intervention at earlier points in the criminal justice process

4 Only 5% of 105 prisons had a specific dual diagnosis service (Forrester et al., 2013).

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(Forrester, Chiu, Dove & Parrott, 2010). Prison in-‐reach teams are under considerable pressure and

do not operate in the way they were originally intended, often offering primary and tertiary care

rather than just secondary. In-‐reach teams are unique in that they operate neither in a community

nor hospital setting but are required to do similar work, albeit with an increased case load and

fewer staff (Forrester et al., 2010). In a recent survey of 105 prisons in the UK, each nurse was seen

to cover approximately 500 prisoners, 29% of prisons had no consultant cover and only 24% had

access to a dedicated psychologist (Forrester et al., 2013). This places considerable pressure on

healthcare professionals attending to mentally unwell offenders and impacts the level and amount

of care able to be offered. Forrester and colleagues (2013) note that the identification of mentally

unwell offenders at the point of entry into prison needs considerable improvement and revision,

with the current screening protocol seemingly insufficient. Bradley (2009) urged that the prison

health screen be evaluated and the assessment of learning disability be incorporated. This is of

particular importance when imprisonment disturbs community mental health support, highlighting

the need for continuous, integrated services between prison and community incorporating

information sharing and continual assessment (Byng et al., 2012). Furthermore the distribution of

in-‐reach services across UK prisons shows much variation and disparity – as such treatment received

by prisoners is not uniform, being compared to a ‘postcode lottery’ (Forrester et al., 2013).

Recommendations have been made with regards to offenders with learning difficulties to improve

staff training, increase opportunities for diversion from prison and the criminal justice system as a

whole as well as improve community support for offenders with learning difficulties (Hayes, 2007).

Qualitative interviews with offenders themselves reveals a desire for less complex language

throughout the criminal process. The court experience can be intimidating and few offenders have

their needs appropriately delineated in pre-‐sentence reports with implications for sentencing (HM

Inspectorate, 2014). Although an appropriate adult should be offered to individuals in police

custody, less than a third receive this (Talbot, 2008). Although training has been noted for criminal

justice professionals in the identification and treatment of mental illness, this has not been

replicated in the domain of learning disabilities (Barron et al., 2004). This is particularly imperative

for prison officers who are on the ‘front line’ and have the most contact with offenders (Bradley,

2009). Staff training is a vital component in the identification and awareness of learning disabilities

in order to implement early diversion and treatment. Screening services in police custody suites

need to be more consistent as well as provide access to previous treatment episodes (Bradley,

2009). Custody sergeants reported confusion over mental health problems and mental capacity and

it was identified that the ‘open plan’ nature of many custody suites impacts the desire to disclose

learning difficulties on arrest. Having a screened off ‘booking in’ area might be one way of

overcoming this observation (HM Inspectorate, 2014). Further, those leaving prison who have

mental health and or learning disabilities who are not subject to probation orders can be neglected –

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their care needs to be continuous despite leaving the criminal justice domain. A mentoring service

has been advocated as one way of overcoming this treatment gap (Bradley, 2009) which is important

in light of feedback from prisoners with intellectual disabilities who did not know who or where they

could turn to upon release (Talbot, 2008).

8. WHAT WORKS

8.1 The existence of modified programmes for offenders with complex needs The existence of modified programmes for offenders with complex needs consolidates

recommendations of early identification in order for specified and tailored treatment. Clearly the

implications of identifying individuals with complex needs is limited if no forms of specialised care or

treatment are practised thereafter. Risk, need and responsivity principles in forensic psychology

highlight the importance in tailoring treatment to individuals’ specific needs, learning abilities and

style in order to make treatment most effective (Andrews et al., 1990).

Prisons recognise the need to support individuals with substance misuse problems through the

utilisation and employment of recovery based wings, integrated drug treatment services,

pharmacological support and counselling, assessment, referral and advice through services (CARAT

teams). Prisoners Addressing Substance Related Offending (P-‐ASRO) (McMurran & Priestly, 2003) is

one cognitive behavioural based programme, designed specifically for substance misusing offenders.

Currently employed across the prison estate, the programme aims to reduce offending though a

decrease in drug-‐taking, appreciating the drug-‐crime link previously discussed. P-‐ASRO has seen

short-‐term success in offending populations (Crane & Blud, 2012). Whilst the data show an

improvement in moving towards action (Stages of Change, Prochaska & DiClemente, 1983), less

impulsivity and greater problem solving ability, P-‐ASRO needs to be tested with regard to specific

substances and reconviction data in order to fully assess its contribution and worth. Furthermore, P-‐

ASRO targets individuals with low to medium dependency despite the acknowledgement that

forensic clients usually meet the criteria for more severe, high dependence (Crane & Blud, 2012).

Mental health in-‐reach teams exist in prisons, although there is considerable disparity across these

services (Forrester et al., 2013), and many prisons have specialised healthcare wings which focus on

the treatment and accommodation of mentally unwell prisoners. Examples of modified programmes

for mentally ill offenders include programmes for firesetting (Swaffer, Haggett & Oxley, 2001) and

more general offender behaviours and thinking styles, such as the modified reasoning and

17

rehabilitation programme (Young & Ross, 2007)5. The need to adapt programmes for offenders with

specific mental health problems (e.g. psychopathy) is imperative as consolidated by high drop-‐out

rates within this cohort (Cullen, Soria, Clarke, Dean & Fahy, 2011).

Research on modified programmes for offenders with learning disabilities exists but is relatively

limited in comparison to programme evaluations for ‘mainstream’ offenders. Where research does

exist this largely falls within the domain of sex offending, perhaps attributable to the over-‐

representation of learning disability within this offence category. Modified programmes generally

constitute amendments to mainstream programmes in order to attend to cognitive impairments

rather than considering differential reasons for offending (Craig & Hutchinson, 2005).

Sexual education courses have also been implemented to consider poor or limited sexual knowledge

in learning disabled offenders (Lindsay, Bellshaw, Culross, Staines & Michie, 1992). Adapted

programmes have been reported to build on the repetitions of simply presented, pictorial

information eliminating and avoiding complex language and information whilst still focusing on

victim empathy and cognitive behaviour elements (Craig et al., 2006). The use of role plays is also

advocated in modified programmes as well as greater time allowed for information to be processed

(Lindsay & Smith, 1998). This can take the form of shorter sessions but with a longer group

programme length overall (Keeling & Rose, 2012). Feedback on, and validation of, modified sexual

offender programmes usually comes in the form of case-‐study reports and therefore it is difficult to

gauge the generalised impact of such programmes as well as their impact on recidivism. Findings do

demonstrate improvements on attitudes consistent with offending, increased self-‐control and sexual

knowledge (Rose, Rose, Hawkins & Anderson, 2012).

Despite small sample sizes, it seems sensible to modify treatment programmes to cater for the

nuanced causation of, and pathways to, offending -‐ particularly in sexual aggression with learning

disabled offenders. Placing learning-‐disabled offenders in a group with sexually deviant and

pathological offenders may be detrimental for their wellbeing and could actually exacerbate

offending behaviour. Recent research has reported on the positive influence of carrying out

modified sex offender programmes in the community and consulting speech and language therapists

in the design and implementation such programmes (Rose et al., 2012). Programmes have also been

modified for learning disabled offenders in the domains of arson (Taylor, Thorne, Robertson &

Avery, 2002) and anger (Burns, Leach & Higgins, 2003), both within forensic secure units.

Recent meta-‐analyses into cognitive behavioural therapy for anger in adults with learning disabilities

acknowledged the need for comparison control groups and larger sample sizes (Nicoll, Beail & Saxon,

2013; Vereenooghe & Langdon, 2013). However, these investigations did not specifically consider 5 This is not UK based but still demonstrates the importance and utility of adapting programmes for offenders with complex needs.

18

offender samples. Whilst research on modified behaviour programmes for offenders with learning

disabilities requires further replication and development, recognition of the need to modify such

programmes is encouraging for offenders with complex needs.

9. CONCLUSIONS & CONSIDERATIONS • This literature review has identified the difficulty in identifying offenders who present with

substance misuse, mental health problems and/or learning disabilities, not least because of the

spectrum of difficulties covered in the range of definitions applied to this cohort. Effective

identification of such individuals is imperative in order to ensure effective, appropriate and

timely care.

• The Corston Report (2007) highlights the need for a “distinct, radically different, visibly-‐led,

strategic, proportionate, holistic, woman-‐centred, integrated approach”

• A jointly agreed and adopted definition between agencies involved in the criminal justice system

could be beneficial.

• Considering the experiences of offenders with complex needs adds weight to this argument as

they report stigma, a lack of understanding about the criminal justice process, bullying, isolation

and victimisation.

• In addition, the correlation between offending and these needs means that investing in

identification and treatment of offenders with complex needs holds great potential societal and

economical value.

• Recommendations from a range of sources, academic and government papers, indicates multi-‐

agency working is vital.

• Individual needs should be identified from the outset, starting at the point of arrest, using

effective, validated and reliable tools.

• Information about such needs should influence treatment options and allow consideration of a

range of sentences (including bail and community orders) in light of evidence on the

vulnerability of offenders with complex needs in custody.

• Support for these needs should be continuous throughout the criminal justice process enhanced

by sharing of information between agencies, to avoid duplication and promote collaboration.

• Once individuals are identified, tailored and adapted treatment should ensue permitting access

to the same level of treatment as ‘mainstream’ offenders.

• Staff should be trained in order to feel competent in identifying, assessing and treating offenders

with complex needs. This is of particular importance for prison officers and other front-‐line

criminal justice staff, such as those operating in police custody suites, probation and in the

community with offenders on release from prison.

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• Offenders with complex needs can provide invaluable feedback about the degree their needs are

being met and should be utilised as a service evaluation and development tool, being consulted

wherever possible.

• Reports such as Patel (2010), Bradley (2009) and the ‘No-‐one knows’ literature are critical in

identifying gaps in service provision, however their recommendations must be acted upon in

order to secure effective support for offenders with complex needs.

In essence, the mantra of ‘no-‐one knows’ should be transformed in to ‘everyone knows’ with

professionals also knowing what to do about it (Jones & Talbot, 2010).

20

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