A more promising architecture? Commissioners’ perspectives on the reconfiguration of personality disorder services under the Offender Personality Disorder (OPD) pathway

Purpose – This paper explores the views of NHS England (NHSE) and Her Majesty’s Prison and Probation Service (HMPPS) commissioners about the Offender Personality Disorder (OPD) pathway. Design/methodology/approach – Thematic analysis of four semi-structured interviews with NHSE and HMPPS commissioners. Findings – Commissioners offered a cautious but confident assessment of the potential effectiveness of the OPD pathway, drawing particular attention to its potential to enhance the confidence and competency of staff, offer better value for money and provide enhanced progression routes for offenders with personality disorders. Additionally, commissioners identified a number of potential risks for the pathway including wider system flux, funding availability, multi-agency working, offender engagement and the need to evidence effectiveness. Research limitations/implications - Our analysis is based on a small number of interviews. However, there are only a limited number of commissioners involved with the OPD pathway. Practical implications - While the stronger focus on progression in the OPD pathway is a welcome departure from a narrow focus on high security DSPD services, the foundations of the OPD pathway ultimately lie with the DSPD programme and similar challenges are likely to follow. The system within which the pathway operates is subject to a great deal of flux and this inevitably poses significant challenges for pathway services, staff and offenders, as well as for those of us charged with its evaluation. Originality/value – There has been limited empirical work with commissioners in the mental health field. Our paper offers a unique insight into the perspectives of those responsible for commissioning the OPD pathway

Non-suicidal self-harm amongst incarcerated men: a qualitative study

Purpose: To further understanding of the needs and motivations of incarcerated men who self-harm with no apparent suicidal intent. These have received little attention in research and policy, despite men accounting for a high and increasing proportion of self-harm in prisons. Methods: Semi-structured interviews were conducted with 20 adult male prisoners with a recent history or thoughts of non-suicidal self-harm. The interviews were analysed drawing on principles of thematic analysis and discourse analysis. Findings: Against a backdrop of early traumatic experiences and more recent adverse events (including prison-related ones), self-harm was described by many as a desperate - but meaningful – coping strategy; both a means of releasing tension, sadness and frustration, and of being heard in an unresponsive system. Value: These findings echo those of research conducted with women (including women prisoners) who self-harm, but challenge some of the more negative ways in which non-suicidal male prisoner self-harm has been portrayed in the (scant) previous literature. As well as pointing to the need for greater awareness of the complex needs of men in prisons, they underscore the importance of (also) exploring - and perhaps addressing - the issue of self-harm separately from suicide, and of striving to make prisons, as well as prisoners, ‘healthier’ and better able to cope with pressure

Rehabilitating antisocial personalities: treatment through self-governance strategies

Offenders with antisocial personality disorder (ASPD) are widely assumed to reject psychotherapeutic intervention. Some commentators, therefore, argue that those with the disorder are better managed in the criminal justice system, where, following the introduction of indeterminate sentences, engagement with psychological treatment is coercively linked to the achievement of parole. By comparison, National Institute of Clinical Excellence guidelines on the management and treatment of ASPD recommend that those who are treatment seeking should be considered for admission to specialist psychiatric hospitals. The rationale is that prison-based interventions are underresourced, and the treatment of ASPD is underprioritised. The justification is that offenders with ASPD can be rehabilitated, if they are motivated. One problem, however, is that little is known about why offenders with ASPD seek treatment or what effect subsequent treatment has on their self-understanding. The aim of this paper is to address these unresolved issues. It draws on the findings of Economic and Social Research Council (ESRC) funded qualitative study examining the experiences of sentenced male offenders admitted to a specialist personality disorder ward within the medium secure estate and the medical practitioners who treat them. The data are analysed with reference to Michel Foucault’s work on governmentality and strategy in power relations. Two arguments are advanced: first, offenders with ASPD are motivated by legal coercive pressures to implement a variety of Foucauldian-type strategies to give the false impression of treatment progress. Second, and related, treatment does not result in changes in self-understanding in the resistive client with ASPD. This presupposes that, in respect of this group at least, Foucault was mistaken in his claim that resistive behaviours merely mask the effectiveness of treatment norms over time. Nevertheless, the paper concludes that specialist treatment in the hospital setting can effect changes in the resistive offender’s self-understanding, but not if the completion of treatment results, as is commonplace, in his prison readmission

Training probation officers in case formulation for personality disordered offenders

Background: The recent UK Strategy on Managing High Risk of Serious Harm Offenders with Severe Personality Disorder proposes a significant role for Offender Managers (OMs) completing case formulations on personality disordered (PD) offenders. However, there is very little evidence as to whether Offender Managers can be taught to carry out case formulation. Aim: The primary aims of this study were to devise and implement a training programme to teach Offender Managers to carry out case formulations, and assess their subsequent ability to do so. A secondary aim was to assess whether the training led to changes in OMs’ attitudes towards working with PD offenders. Method: A five day training programme was delivered to 20 Offender Managers, whose ability to carry out case formulation was assessed before and after the training using a 10 point quality checklist. Attitudes towards PD were also assessed before and after. Qualitative feedback relating to the training was used to provide further insight into the findings. Results: Offender Managers showed a significant improvement in their ability to carry out case formulation following training with 7 out of the 10 quality domains on the quality checklist rated as at least ‘satisfactory’ post-training. Qualitative feedback highlighted reasons for some of the shortfalls in two of the three areas that did not show improvement. Improvements were shown in attitudes towards working with PD offenders in two out of three domains. Conclusion: This study provides some evidence for Offender Managers’ ability to carry out case formulation following training, improvements in attitudes towards working with PD offenders and difficulties specific to this addition to their current role

Shifting the paradigm of prison suicide prevention through enhanced multi-agency integration and cultural change

This study examines an unusually sustained reduction in suicide rates in a local London prison during the three year period 2008-2011. The likelihood of this reduction taking place by chance was < 2:100,000, and its perceived success was such that the prison service recommended an evaluation of its characteristics. This study arose from that recommendation, and it used a retrospective case study multi-method approach (including factor identification, qualitative interviews, and triangulation with official documentation) to identify factors which had been associated with the reduced suicide rates. The results endorsed a number of factors which have already been internationally identified as best practice (WHO, 2007), along with some local innovation factors. Two further pivotal factors emerged through analysis, and they are key to service improvements. These factors - senior management support for cultural change and cross-professional collaborative working - indicate that positive leadership and multi-agency integration are vital ingredients

Getting underneath the skin: A community engagement event for optimal vitamin D status in an 'easily overlooked' group

BACKGROUND: Patient and public involvement and engagement (PPIE) is recognized as important for improved quality in health service provision and research. Vitamin D is one area where PPIE has potential to benefit public health initiatives, particularly for women and children with increased skin pigmentation (ie at high risk of deficiency) who are easily overlooked. OBJECTIVE: We report findings from a community PPIE event that explored the knowledge, barriers and promoters for optimal vitamin D status amongst an exemplar high-risk and easily overlooked population group. METHODS: Two researchers and one PPIE lead facilitated a single group discussion with twenty members of the Somali community from across west London. All attendees were women of reproductive age, or knew a mother and child that could benefit from a targeted initiative. The discussion was recorded, transcribed verbatim, organized and coded using NVivo 12 Pro to identify emergent themes underpinned by the Health Behaviour Model. RESULTS: Attendees thought community safety and competing demands of technology and education impacted on sun exposure and lifestyle activity. Language barriers impacted on access to health care. Attendees also felt the mother figure was 'the most important' influencer of both child and wider community health. DISCUSSION: Although further discourse is needed, this event emphasizes that it is important that the public voice is heard in informing, designing and evaluating appropriate public health interventions amongst specific ethnic groups. Insights from this Somali population have suggested benefit from using verbal health messages that are specifically targeted at mothers, compared with the general population

NHS commissioning in probation in England – still on a wing and a prayer

Policy reforms in England and Wales mean that all individuals released from prison will have some contact with probation services, either serving a community sentence, or being on licence postrelease. Despite often having complex health needs, including a higher prevalence of mental illness, substance misuse problems and physical health problems than the general population, this socially excluded group of people often do not access healthcare until crisis point. This is partly due to servicelevel barriers such as a lack of appropriate and accessible healthcare provision. We conducted a national survey of all Clinical Commissioning Groups (CCGs, n=210) and Mental Health Trusts (MHTs, n=56) in England to systematically map healthcare provision for this group. We compared findings with similar surveys conducted in 2013 and 2014. We had excellent response rates, with the data analysed here representing responses from 75% of CCGs and 52% of MHTs in England. We found that just 4.5% (n=7) of CCG responses described commissioning a service specifically for probation service clients, and 7.6% (n=12) described probation-specific elements within their mainstream service provision. Responses from 19.7% of CCGs providing data (n=31) incorrectly suggested that NHS England are responsible for commissioning healthcare for probation clients rather than CCGs. Responses from 69% (n=20) of MHTs described providing services specifically for probation service clients, and 17.2% (n=5) described probation-specific elements within their mainstream service provision. This points to a need for an overarching health and justice strategy that emphasises organisational responsibilities in relation to commissioning healthcare for people in contact with probation services to ensure that there is appropriate healthcare provision for this group

Transfers from prison to hospital under Sections 47 and 48 of the Mental Health Act between 2011 and 2014

In England and Wales, prisoners with mental disorder of such severity as to warrant inpatient treatment may be transferred to hospital under the Mental Health Act. UK Government guidance recommends that this process should be completed within 14 days; however, evidence suggests that in many cases it can take much longer. This retrospective service evaluation of 64 male prisoners, who were transferred under Section 47 or Section 48, aimed to evaluate transfer durations. The mean time from referral to admission was 76 days. Prisoners with a psychotic disorder were admitted more quickly. Remand prisoners were admitted more quickly than sentenced prisoners. Findings suggest that, in the UK the transfer time of prisoners under Sections 47 and 48 of the Mental Health Act continues to far exceed the 14-day target which raises concern about equivalence of care for prisoners. Our findings support arguments for fundamental amendments to the admissions process

Time and its uses in accounts of conditional discharge in forensic psychiatry

This paper presents an analysis of time relevant talk by patients and workers in forensic mental health care services. In doing so it presents new knowledge of the use of time and its patterning in contemporary mental health care. Regularities and discontinuities in discharge and aftercare planning are examined. Regularities include timed phases for movement towards discharge and other discretionary aftercare arrangements. Discontinuities include awareness of mismatches between discharge plans and arrangements often between hospital and community based resources. Bench-marking is evident in which individuals gauge progress or lack of it against others within the system. Time also functions as a resource for establishing distance between past selves and current or imagined future identities. Time is therefore an important feature in building post-hospital lives. Workers for their part position time as one element in a complex series of judgments on post-discharge constructions of the person and their risk status