When prison is “easier”: probationers’ perceptions of health and wellbeing Emma Plugge, Anees Ahmed Abdul Pari, Janet Maxwell and Sarah Holland
Dr Emma Plugge is a University Research Lecturer, based at Department of Public Health, University of Oxford, Oxford, UK. Dr Anees Ahmed Abdul Pari is a Academic Clinical Fellow, based at Health Economics Research Centre, Department of Public Health, University of Oxford, Oxford, UK. Dr Janet Maxwell is a Director of Public Health, based at NHS Berkshire West, Reading, UK. Sarah Holland is a Senior Probation Officer, based at Thames Valley Probation, Reading, UK.
Abstract Purpose – There are currently over 300,000 offenders in England and Wales and the majority, around 240,000, are in the community on probation. However, there is a paucity of research on their health and healthcare needs. The purpose of this paper is to explore issues around health and access to health services for those on probation. In particular the paper explores what people on probation consider to be the key health issues currently affecting them, and to identify barriers to accessing healthcare in the community. Design/methodology/approach – The authors ran six focus groups with a total of 41 participants; two were with staff and the others with men and women on probation. In each focus group, the researchers used semi-structured guide and the discussions were recorded electronically and then transcribed. The paper adopted a thematic analytical framework and used NVivo 7 to facilitate analysis. Findings – Both probationers and professionals largely agreed about the key issues which included substance use and mental health problems. However, the most important issue for probationers was dealing with the stress of being on probation which was not generally recognised by professionals. All participants recognised the impact of issues such as housing, finances and employment on the wellbeing of probationers and were concerned about the lack of access to health services, in particular mental health and alcohol services. Research limitations/implications – This was a small study conducted in one part of England and therefore it is not clear that the findings are generalisable. However, it raises important issues about the mental health needs of probationers and the lack of appropriate services for them. Effective services may have positive impact on re-offending and further research is needed to evaluate models of care. Practical implications – The challenge remains for local health service commissioners and providers and the probation service to work together to provide appropriate and accessible services for all those on probation. Originality/value – Nearly one-quarter of a million people are on probation at any one time in the UK but the existing evidence on their health is patchy and dated. Little is known about effective health interventions or the extent to which their health needs are met. This study shows that probationers see the stress of being on probation as their most important health concern. Both probationers and staff recognise that mental health and substance use are persistent problems and that these important health needs in these areas are not being met by existing services. Keywords Criminal justice system, Qualitative research, Psychological health, Mental illness Paper type Research paper
The authors would like to thank all the participants who kindly gave up their time to participate in the focus groups. The authors are also grateful to Ana Palanca, Karolina Rainsbury, Andrew Bates, Ukonu Obasi, Raphaella David, Gabriel Amahwe, Ray Fitzpatrick, Premila Webster, and staff at the Newbury and Reading branches of Thames Valley Probation Agency and the hostels involved.
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Introduction There are currently around 300,000 offenders in England and Wales and the majority, around 230,000, are in the community on probation (Ministry of Justice, 2013). Probation services are provided to these individuals at a local level by one of the 35 probation trusts. These trusts are not, however, responsible for delivering health services to people on probation; these services are provided by the National Health Service (NHS) and commissioned by the new Clinical Commissioning groups (CCGs) from 1 April 2013. It is recognised that commissioners should jointly plan services for offenders with probation trusts and other key stakeholders to ensure
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DOI 10.1108/IJPH-01-2013-0001
effective commissioning and delivery of services (Bradley, 2009). However, very little is known about health needs of probationers and this creates difficulties for effective commissioning of health services. The existing evidence on the health of probationers is rather patchy and dated. Work conducted in the 1990s demonstrated that the self-reported health of probationers was poorer than the general population (Mair and May, 1997). More recently, a survey for 183 offenders managed under Nottinghamshire and Derbyshire probation services in England, found that the physical and mental health of probationers was significantly worse than the general population (Brooker et al., 2009). Other work has highlighted the high prevalence of mental health, alcohol and substance use in the probation population; around 50 per cent of probationers have an alcohol and mental health problem, and 25 per cent have issues related to drug abuse (Solomon and Silvestri, 2008). Similarly, studies have also shown high levels of mental health need (Ryan et al., 2005) demonstrating that 25 per cent residents had an existing psychiatric illness, 34 per cent had problems with substance abuse, and 31 per cent had issues related to alcohol abuse. They also found that the proportion of probationers reporting long-term health conditions was similar to the one observed in prisons. The high prevalence of mental health problems has been highlighted by several researchers (Brooker et al., 2009, 2012; Ryan et al., 2005; Crilly et al., 2009) although a recent review has demonstrated wide variations in estimates of prevalence rates (Sirdifield, 2012). However, some of the variation might be attributed to the differences in the probation populations in the 18 papers studied. It has been shown that provision of mental healthcare has shown to reduce the overall re-offending rates, and associated violence (Herinckx and Swart, 2005; McNiel and Binder, 2007). Given the high level of mental health needs in offenders, identification of these needs and engagement with mental health service is essential. Lord Bradley’s report acknowledges the central importance of promoting, and protecting mental health in offenders, and advocates for timely assessment and diversion programmes in criminal justice systems (Bradley, 2009). Moreover, it is likely that many probationers have physical health problems. Not only is selfreported health poor (Mair and May, 1997; Brooker et al., 2009) but researchers have also examined specific health problems such as sexual health. Studies have shown that probationers engage in unsafe sexual practices, and have high rates of HIV infection ranging from 13 to 32 per cent (Belenko et al., 2004; Oser et al., 2006). The rates of sexually transmitted infections (STIs) in offenders are substantially higher than the general population (Hammett and Harmon, 1999). Offenders managed in the community are more likely than prisoners to have higher opportunities to engage in high-risk behaviours, and unsafe sexual practices that not only elevate their risk of acquiring HIV and other STIs, but also put their partners in the general population at higher risk of contracting STIs including HIV. To date there has been no systematic assessment of the health needs of probationers in the Thames Valley to inform effective health service delivery. Furthermore little is known about probationers’ perceptions of their health or health needs. This work, conducted in 2011, was therefore undertaken to fill these gaps and the qualitative research reported in this paper was part of a larger study examining the health need of probationers in Berkshire. The aim of this specific aspect of the study was to explore issues around health and access to health services for those on probation. More specifically, we wanted to explore what people on probation consider to be the key health issues currently affecting them, and to identify barriers that prevent them from accessing and utilising healthcare in the community, and how these might be addressed.
Methods Settings and participants The health of probationers is a poorly researched area and our study group consisted of individuals who are generally considered a “hard to reach” population (Gough, 2005). Given the challenges associated with engagement and poor literacy, focus groups were considered the most appropriate method for achieving our aims. This is a poorly researched area and focus groups are a good exploratory method, providing a means of quickly establishing the range of
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perspectives and the relative importance the group gives to these ideas (Fitzpatrick and Boulton, 1994; Kitzinger, 1995). We ran a total of six focus groups with a total of 41 participants in Berkshire, England. Two were with staff: one with probation officers and one with those professionals who work for a range of partner organisations. We ran a further four groups with individuals on probation: three with men and one with women. One of the groups with men and the group with women took place in their residential hostel. The other two groups with men took place on their community service work placement. Groups were held in private areas or rooms to ensure confidentiality. All participants were given an information sheet and those who wished to participate gave written consent. Participants were assured of confidentiality and anonymity, subject to the proviso that we were required to report to the probation service disclosures of intention to self-harm, harm another or if child protection concerns were raised. Ethics approval was granted by the University of Oxford’s Research Ethics Committee and the conduct conformed to the principles embodied in the Declaration of Helsinki. Data collection In each focus group, two researchers (E.P. and A.P.) used a semi-structured guide which aimed to explore the probationers’ perceptions of the health problems of probation and their experiences of healthcare services and recommendations for service development. The questions are shown in Box 1. The researchers explored staff perceptions of probationers’ health issues and how these needs might be addressed. Each group comprised between three and ten individuals (see Table I) and lasted between 30 and 75 minutes. The two researchers facilitated each group. The discussions were recorded electronically and then transcribed. Analysis NVivo 7 was used to facilitate analysis. We adopted a thematic analytical framework and used an inductive approach to identify themes related to our overall broad study objectives (Braun and Clarke, 2006). Our analysis was driven by a detailed semantic description of gathered data and not by pre-conceived theories. Two researchers (A.P. and E.P.) independently coded and analysed the data. After familiarising ourselves with the data, we categorised and collated major themes and sub-themes to form patterns within the data. We also examined the data for deviant cases and then reviewed and discussed their interpretations, resolving the few minor differences that emerged as coding progressed.
Box 1: Questions asked during the interviews ’
What would you say are the sorts of health problems people on probation might have?
’
Who has used the health services since being on probation this time? Which ones?
’
From your experience, we want you to identify the good things about the services that you have used recently and the bad things.
’
Please could each person say one way in which they would improve health services?
Table I Composition of focus groups
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Focus group
Location
1. 2. 3. 4. 5. 6.
Probation hostel At work Probation hostel Probation premises Probation premises At work
Probationers Probationers Probationers Professionals: partner organisations Professionals: probation officers Probationers
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Number of participants
Gender
Age range
6 3 7 9 10 6
Male Male Female Mixed Mixed Male
31-60 19-60 21-59 33-58 28-54 22-58
Findings Health: a low priority Most participants had a clear idea of the various health problems encountered by individuals on probation. Both staff and the probationers alike were able to identify a number of key health concerns. However, both those on probation and the groups of professionals identified that health was not a priority issue for probationers. They had much more pressing concerns. These might be finding employment or appropriate housing, or for those with ongoing alcohol and drug problems, meeting the needs of their addiction: Bottom of the pile. It’s the last thing they want to do [y] get yourself a balanced diet and a goodnight’s sleep! (Focus group 4). I don’t know much about health, but you see some people who die like instantly like heart attack, run over by buses, so in a way I reckon you just should be like yourself and not worry too much about health and like that. (Focus group 2).
The stress of being on probation Despite the fact that health and a healthy lifestyle were a low priority, the probationers themselves were able to identify a range of health concerns. The most important health concern, identified by all groups, was the stress caused by being on probation. As one probationer succinctly noted, “I think stress and strain is the biggest health issue”. All groups identified a number of reasons why being on probation was so stressful although the specific reasons varied from focus to focus group; they appeared to depend on where the individual was placed. However, a key theme was the power of the probation officers; probationers felt they were at the mercy of their probation officer who used their professional position to threaten rather than support them: I’ve been out 11 months and I can’t think of one single thing my probation officer has done for me. Me neither Me neither – no I got a CSCS [construction skills certification scheme] card (general murmurings of agreement) I was out two weeks before I saw my probation officer. He was too busy to come and visit me! I could do whatever I wanted. There’s no sort of building a foundation to start with – finding a job or employment or housing. (Focus group 1). We’re just guinea pigs aren’t we? My probation officer (I really don’t like her) and she’s stopping me seeing my mum and my family so it feels like she’s setting me up to go back to prison. We are like guinea pigs; they can do what they like to us. It’s not fair. (Focus group 3).
What they wanted from their probation officer was someone to help them move forward, help them address their needs such as housing and employment. However, the majority felt that they did not do that. They were slow to provide the information they required yet quick to threaten them with the prospect of returning to prison. They found that the control probation officers exerted over them to be a source of considerable stress: They don’t try to help you They don’t put you in touch with the people who are going to help you. Or sign you to them [y] they don’t do that. (Focus group 1). [Probation officers] they stress you out even more [y] you done a crime, right, but they should talk to you about the positives. You want to turn back the hand of time, right? But you can’t. They keep asking you the question about the past [y]. (Focus group 2).
Although the majority of the men found their probation officers less than helpful, there was some disagreement in the women’s group. Some women found their probation officer helpful although others were quick to identify problems with theirs. All these women were located within a hostel and had established positive relationships with the hostel staff. This was in marked contrast to the men’s hostel where residents perceived staff to be unhelpful and cited occasions when their
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actions had been dangerous. One resident identified the time when they had given him too much of his prescribed medication and another described an occasion earlier in the year when they had neglected the health needs of a drug using resident who was subsequently found dead in his room. Many felt that a range of other health problems were directly attributable to the stress they experienced including depression, smoking and substance use: Alleviating stress – that’s drugs and drink [y]. There’s a lot of stress in here, a lot of stress. You want to change, you want to get your life back on track and then people in here think they know and telling you to do things they think will be good for you – the stress! If you drag on a fag, it calms you down a bit, doesn’t it? I never smoked in jail but here! (Focus group 1).
Prison or probation? All groups talked about the differences between prison and being on probation. There was a general consensus amongst the men that prison was preferable and that things there were “easier” as they were provided with shelter and meals three times a day. There was also more certainty: the provision of information was standardised through induction programmes and individuals knew what they should be doing at a given time. Furthermore, it was much simpler to access a range of health services as these were obviously located within the prison: I’d rather be in prison than here but I suffer this for my family. I’d love to be in a prison cell right now. Knowing what I’m gonna do. Knowing everything’s gonna be alright [y]. (Focus group 1). I wish I didn’t have to do this. But it goes back to consequences. You could get paid for this. A lot of people they prefer to go to jail but if you got paid for this [y] they’re like ‘it’s so easy to go to jail.’ (Focus group 2).
This was also acknowledged by the professionals: I think what is striking sometimes is that quite a lot is people in the community who can’t cope with addressing their addiction like to go to prison. ‘I want to go to prison – that is the only place I can get clean’. And HMP Detox is sort of like that is what they see really. I can get clean in prison, can come out and start again, and I think that is quite a sad place to be really. That is actually a combination of accessing service, but also about their motivation. They are forced to do it. It is a lot easier somehow to address it while you are in custody. (Focus group 4).
The women on probation had a different view and considered being in the hostel preferable to being in prison. However, one woman who had experience of another hostel could see that whether or not prison appeared preferable depended very much on where you were located when on probation. She had a lot of praise for her current placement where she felt safe and supported and was alcohol and drug free, but she had previously been in another, very different hostel: Here you learn slowly how to integrate into the community. [In prison] you’re safe but so institutionalized [y] [Last time I came out of prison] I did find it hard to integrate. I did manage to get to a hostel but it wasn’t all female, there were lots of drugs going around, lots of alcohol. They didn’t force me to fail but I wish I’d had the support what I’ve got now [here] then maybe I wouldn’t have ended up in prison again [y] The other hostel was completely different. I didn’t feel safe there where here I feel safe and, I have the support [y] The staff here is really nice. (Focus group 3).
Mental health and substance use In addition to stress and depression, smoking and substance use related to this stress, those on probation also recognised a range of other health issues. Alcohol and substance use and mental health issues were recognised as considerable problems in themselves. Alcohol was a particular concern. It was seen as socially acceptable, widely advertised and easily accessible. However, whilst the substance itself was easily accessible, this was not the case with appropriate services and support for those with alcohol problems as participants in the FGD below discuss: From my point as an alcoholic, more support for alcoholics [is needed]. Not just detox and then thrown out on the street again [y] You have more support as a drug addict than an alcoholic. There’s just not enough support fullstop. Considering how many people it kills [y] They’ve stopped all
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the cigarette advertising but alcohol – phaff! Every TV series you watch they’re down the pub, commercials, billboards, everywhere. It’s available – everywhere! If you’re an alcoholic you get given your antabuse whatever to get off of it but it’s the actual support afterwards because it whether you do the detox you still got it in your head mentally that you want the alcohol not something that’ll block it. And I know it takes willpower as well but it would be good if there was something they could give you that stopped the urge, the feeling. And it’s so easily available [y]. When you get the urges you need the support. It’s definitely something that’s lacking in the NHS. It’s not the detox as I have been [y] they detox in three days and then you’re out and there’s an off license round the corner! I had immense support in rehab [y] I’ve got a lot of support here. The NHS need to step up [treatment of alcohol]. (Focus group 3).
Mental health issues were also a concern, again because many people with depression felt their needs were not being met. These participants explained: Depression is a big issue [y] it’s what got me here. People [with depression] are put to the side and then something serious happens so they think they’ll do something now but it’s too late [y] when it comes down to mental health it shouldn’t be the case [that there’s a crisis]. If you really need support it’s not there. Then you end up self harming, trying to commit suicide or a crime against someone else, seriously hurt someone else like I did [y]. I asked for help, I was crying out for help, but I wasn’t given it. (Focus group 3).
The lack of appropriate and timely mental health services were also raised by the professionals. They felt, as did the probationers themselves, that services in the community were not sufficiently comprehensive and people were allowed to “fall though the gaps”. This meant that the community mental health crisis team were not willing to intervene or help until a crisis point was reached. Only if the crisis had resulted in an offence, they would then be identified by the local court diversion team and fast tracked into mental health services as appropriate. At other times, the probation officers themselves were simply left to manage the individual as best they could despite their lack of mental health training: The crisis team has services, but it is very much about, we get an offender phone up say they are gonna kill themselves, if they have been working with them for a while, they are just like, ‘look the guy has personality disorder, and they do this all the time.’ But, we are dealing with someone who goes in crying for help, and even if they have no intention of killing themselves, it is pretty desperate to be even saying that, and it needs assessment by a health professional at that stage. Offenders will call up their offender managers even if they don’t have appointments specifically to disclose that, ‘I am feeling so low, I am feeling suicidal.’ (audible agreement by other participants) Or they will call up and say, ‘please can you phone up the police’ and ‘I don’t want them to find my body when there are maggots in my mouth’ [y] Then you have to try deal with that conversation, and if you’re dealing with mental health services, they are like – yeah, this person does this all the time. But you are sort of struck with what do I do with that? (Focus group 5).
The professionals identified a number of other areas of mental health provision which they felt were lacking. There was a lack of services for people with personality disorders and these individuals comprised a substantial proportion of their caseload. Similarly they felt the services for those with learning disabilities were lacking in terms of identification and on-going support. In addition there was a lack of talking therapies for people with anxiety and depression, which they identified as being considerable health concerns amongst their client group.
Discussion Both probationers and professionals identified a range of health issues. They largely agreed about the key issues which included substance use and mental health problems. However, the most important issue for probationers was dealing with the stress of being on probation. This was not generally recognised by professionals, who were identified as being part of the problem by probationers. All participants recognised the impact of issues such as housing, finances and employment on the wellbeing of probationers and were concerned about the lack of access to health services, in particular mental health services and comprehensive alcohol services, and how this affected probationers’ health.
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Participants in this study identified mental health and substance use as key issues and this is in line with health surveys of probationers that have quantified this problem (Mair and May, 1997; Brooker et al., 2009; Ryan et al., 2005; Crilly et al., 2009; Abdul Pari et al., 2012). However, it was concerning that these were areas where health service provision was considered to be particularly deficient by staff and probationers alike. Furthermore, it was concerning that individuals whose crimes were not attributed to any mental illness were neither considered to be at risk of mental health issues nor offered any support for “less severe mental disorders” such as depression or personality disorders. Despite the recent emphasis on mentally ill offenders (Bradley, 2009) and the apparent success, at least locally, of court diversion schemes, these findings suggest more needs to be done “upstream”. There is a need to engage these individuals earlier in effective treatment and thus perhaps prevent them from re-offending at all. Improved continuity of care from prison to the community may be an area for further investigation. Alcohol use is a significant concern for many probationers and there was a perception that effective services are lacking. The high prevalence of alcohol use in probationers has been reported elsewhere (Abdul Pari et al., 2012; Brooker et al., 2009; Solomon and Silvestri, 2008) and clearly the important challenge locally is the development of accessible services for these individuals which will provide not simply the drug treatments for detox but longer term counselling and support services. It will be important to determine what impact these services have not just on the health of probationers but on re-offending rates too. Given the well-established links between alcohol consumption and crime (Graham et al., 2012), effective services are likely to have a beneficial impact on re-offending. It was notable that the male probationers saw prison as an easier way of serving their sentence than being on probation. They could see the advantages of the routine, the three times meals a day, and the easy access to healthcare. This is perhaps surprising: institutionalisation is not usually seen as a good thing. Indeed the Oxford English Dictionary definition of institutionalized is “Of a person: confined to an institution. By extension, usually of a long-term patient or prisoner: adversely affected, esp. made apathetic or dependent, by prolonged institutional confinement” (Oxford English Dictionary, 2013). This definition suggests that it is a negative experience. Goffman (1968), who wrote extensively on the failings of institutions, noted over 40 years ago that “There are certain bodily comforts significant to the individual that tend to be lost upon entrance into a total institution – for example, a soft bed or quietness at night”. However, the male probationers in this study could see the advantages of being in prison, highlighting “bodily comforts” that were available to them. This is an area that would be worth exploring with further research. This study has highlighted some key areas for health service development and will inform the planning of services for this group of individuals in the local community. It is the first time such a study has been conducted in this geographical area and provides useful information not only for health services but also the probation service itself and their partners. It has added to the evidence base on the health of probationers, a largely neglected group; paradoxically more is known about the health of the 88,000 prisoners in England and Wales although there are 230,000 offenders in the community. As noted in the introduction, the NHS in England is currently undergoing major reform with CCGs taking responsibility for commissioning services for the local community, including probationers (National Health Service Commissioning Board, 2013). CCGs would become part of local community safety partnerships (CSP) and contribute to the strategic needs assessment of crime, anti-social behaviour, re-offending and substance abuse for their defined CSP areas (Health and Social Care Act, 2012). While, the extent to which CCGs are involved and their role in shaping delivery of high-quality care for probationers is still unclear, this change creates an opportunity to develop services for this hitherto neglected group. However, with considerable public service cuts, there is also a risk that these vulnerable individuals are forgotten. We would echo Brooker et al.’s (2012) assertion that there is a need for a national study of the prevalence of mental health disorders in probation populations in the UK and suggest that such a study should look beyond mental health to include a full range of health issues and associated costs. Without this information, the magnitude of the problem will remain poorly documented and therefore more likely to be ignored by local commissioners and national policy makers. Furthermore, we
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should examine models of care in other countries, such as the USA, where there are similar challenges (Lurigio, 2011). Although the qualitative methods used were appropriate for the study question, and the participants’ accounts were credible with considerable agreement between staff and probationers, further validation of the findings should ideally have been undertaken. Resource and time constraints meant that the researchers were not able to present the findings to participants for verification. Nor, given that we did not aim to obtain a sample representative of all probationers, are the findings widely generalisable. However, we wanted to gain the views of a broad range of key groups of probationers (those in post release hostels and those on community service) and of professionals. We were able to achieve this and, despite the heterogeneous groups and the small sizes, the themes identified from analysis of the data were remarkably consistent.
Conclusions Improving the health of offenders on probation is not only important for the offenders, but also for their friends, family and wider community. Identifying and effectively addressing probationers’ health needs is likely to have major impact on decreasing their burden of illness, particularly mental disorders and alcohol related problems, while reducing re-offending. The challenge remains for local health service commissioners and providers and the probation service to work together at this time of organisational change in the NHS and the probation service in order to provide appropriate and accessible services for all those on probation.
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Herinckx, H.A. and Swart, S.C. (2005), “Rearrest and linkage to mental health services among clients of the Clark County mental health court program”, Psychiatric Services, Vol. 56 No. 7, pp. 853-7. Kitzinger, J. (1995), “Qualitative research: introducing focus groups”, BMJ, Vol. 311 No. 7000, pp. 299-302. Lurigio, A. (2011), “People with serious mental illness in the criminal justice system: causes, consequences and correctives”, The Prison Journal, Vol. 9 No. 3, pp. 66S-B6S. McNiel, D.E. and Binder, R. (2007), “Effectiveness of a mental health court in reducing criminal recidivism and violence”, American Journal of Psychiatry, Vol. 164 No. 9, pp. 1395-403. Mair, G. and May, C. (1997), Offenders on Probation, Home Office, London. Ministry of Justice (2013), Offender Management Statistics Quarterly Bulletin, Ministry of Justice Statistics Bulletin, London, July-September 2012. National Health Service Commissioning Board (2013), “Commissioning development”, available at: www. commissioningboard.nhs.uk/ourwork/com-dev/ (accessed 28 February 2013). Oser, C.B., Leukefeld, C.G. and Tindall, M.S. (2006), “Male and female rural probationers: HIV risk behaviors and knowledge”, AIDS Care, Vol. 18 No. 4, pp. 339-44. Oxford English Dictionary (2013), Oxford English Dictionary, Oxford University Press, Oxford, available at: www.oed.com/view/Entry/252092 (accessed 23 April 2013). Ryan, T., Hatfield, B. and Downing, B. (2005), “A follow up-study of probation service-approved premises residents in contact with mental health services”, Journal of Forensic Psychiatry & Psychology, Vol. 16 No. 4, pp. 699-713. Sirdifield, C. (2012), “The prevalence of mental health disorders amongst offenders on probation: a literature review”, J Ment Health, Vol. 21 No. 5, pp. 485-98. Solomon, E. and Silvestri, A. (2008), Community Sentences Digest, Centre for Crime and Justice Studies, King’s College London, London.
Corresponding author Dr Emma Plugge can be contacted at: [email protected]
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Dr Emma Plugge is a University Research Lecturer, based at Department of Public Health, University of Oxford, Oxford, UK. Dr Anees Ahmed Abdul Pari is a Academic Clinical Fellow, based at Health Economics Research Centre, Department of Public Health, University of Oxford, Oxford, UK. Dr Janet Maxwell is a Director of Public Health, based at NHS Berkshire West, Reading, UK. Sarah Holland is a Senior Probation Officer, based at Thames Valley Probation, Reading, UK.
Abstract Purpose – There are currently over 300,000 offenders in England and Wales and the majority, around 240,000, are in the community on probation. However, there is a paucity of research on their health and healthcare needs. The purpose of this paper is to explore issues around health and access to health services for those on probation. In particular the paper explores what people on probation consider to be the key health issues currently affecting them, and to identify barriers to accessing healthcare in the community. Design/methodology/approach – The authors ran six focus groups with a total of 41 participants; two were with staff and the others with men and women on probation. In each focus group, the researchers used semi-structured guide and the discussions were recorded electronically and then transcribed. The paper adopted a thematic analytical framework and used NVivo 7 to facilitate analysis. Findings – Both probationers and professionals largely agreed about the key issues which included substance use and mental health problems. However, the most important issue for probationers was dealing with the stress of being on probation which was not generally recognised by professionals. All participants recognised the impact of issues such as housing, finances and employment on the wellbeing of probationers and were concerned about the lack of access to health services, in particular mental health and alcohol services. Research limitations/implications – This was a small study conducted in one part of England and therefore it is not clear that the findings are generalisable. However, it raises important issues about the mental health needs of probationers and the lack of appropriate services for them. Effective services may have positive impact on re-offending and further research is needed to evaluate models of care. Practical implications – The challenge remains for local health service commissioners and providers and the probation service to work together to provide appropriate and accessible services for all those on probation. Originality/value – Nearly one-quarter of a million people are on probation at any one time in the UK but the existing evidence on their health is patchy and dated. Little is known about effective health interventions or the extent to which their health needs are met. This study shows that probationers see the stress of being on probation as their most important health concern. Both probationers and staff recognise that mental health and substance use are persistent problems and that these important health needs in these areas are not being met by existing services. Keywords Criminal justice system, Qualitative research, Psychological health, Mental illness Paper type Research paper
The authors would like to thank all the participants who kindly gave up their time to participate in the focus groups. The authors are also grateful to Ana Palanca, Karolina Rainsbury, Andrew Bates, Ukonu Obasi, Raphaella David, Gabriel Amahwe, Ray Fitzpatrick, Premila Webster, and staff at the Newbury and Reading branches of Thames Valley Probation Agency and the hostels involved.
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Introduction There are currently around 300,000 offenders in England and Wales and the majority, around 230,000, are in the community on probation (Ministry of Justice, 2013). Probation services are provided to these individuals at a local level by one of the 35 probation trusts. These trusts are not, however, responsible for delivering health services to people on probation; these services are provided by the National Health Service (NHS) and commissioned by the new Clinical Commissioning groups (CCGs) from 1 April 2013. It is recognised that commissioners should jointly plan services for offenders with probation trusts and other key stakeholders to ensure
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DOI 10.1108/IJPH-01-2013-0001
effective commissioning and delivery of services (Bradley, 2009). However, very little is known about health needs of probationers and this creates difficulties for effective commissioning of health services. The existing evidence on the health of probationers is rather patchy and dated. Work conducted in the 1990s demonstrated that the self-reported health of probationers was poorer than the general population (Mair and May, 1997). More recently, a survey for 183 offenders managed under Nottinghamshire and Derbyshire probation services in England, found that the physical and mental health of probationers was significantly worse than the general population (Brooker et al., 2009). Other work has highlighted the high prevalence of mental health, alcohol and substance use in the probation population; around 50 per cent of probationers have an alcohol and mental health problem, and 25 per cent have issues related to drug abuse (Solomon and Silvestri, 2008). Similarly, studies have also shown high levels of mental health need (Ryan et al., 2005) demonstrating that 25 per cent residents had an existing psychiatric illness, 34 per cent had problems with substance abuse, and 31 per cent had issues related to alcohol abuse. They also found that the proportion of probationers reporting long-term health conditions was similar to the one observed in prisons. The high prevalence of mental health problems has been highlighted by several researchers (Brooker et al., 2009, 2012; Ryan et al., 2005; Crilly et al., 2009) although a recent review has demonstrated wide variations in estimates of prevalence rates (Sirdifield, 2012). However, some of the variation might be attributed to the differences in the probation populations in the 18 papers studied. It has been shown that provision of mental healthcare has shown to reduce the overall re-offending rates, and associated violence (Herinckx and Swart, 2005; McNiel and Binder, 2007). Given the high level of mental health needs in offenders, identification of these needs and engagement with mental health service is essential. Lord Bradley’s report acknowledges the central importance of promoting, and protecting mental health in offenders, and advocates for timely assessment and diversion programmes in criminal justice systems (Bradley, 2009). Moreover, it is likely that many probationers have physical health problems. Not only is selfreported health poor (Mair and May, 1997; Brooker et al., 2009) but researchers have also examined specific health problems such as sexual health. Studies have shown that probationers engage in unsafe sexual practices, and have high rates of HIV infection ranging from 13 to 32 per cent (Belenko et al., 2004; Oser et al., 2006). The rates of sexually transmitted infections (STIs) in offenders are substantially higher than the general population (Hammett and Harmon, 1999). Offenders managed in the community are more likely than prisoners to have higher opportunities to engage in high-risk behaviours, and unsafe sexual practices that not only elevate their risk of acquiring HIV and other STIs, but also put their partners in the general population at higher risk of contracting STIs including HIV. To date there has been no systematic assessment of the health needs of probationers in the Thames Valley to inform effective health service delivery. Furthermore little is known about probationers’ perceptions of their health or health needs. This work, conducted in 2011, was therefore undertaken to fill these gaps and the qualitative research reported in this paper was part of a larger study examining the health need of probationers in Berkshire. The aim of this specific aspect of the study was to explore issues around health and access to health services for those on probation. More specifically, we wanted to explore what people on probation consider to be the key health issues currently affecting them, and to identify barriers that prevent them from accessing and utilising healthcare in the community, and how these might be addressed.
Methods Settings and participants The health of probationers is a poorly researched area and our study group consisted of individuals who are generally considered a “hard to reach” population (Gough, 2005). Given the challenges associated with engagement and poor literacy, focus groups were considered the most appropriate method for achieving our aims. This is a poorly researched area and focus groups are a good exploratory method, providing a means of quickly establishing the range of
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perspectives and the relative importance the group gives to these ideas (Fitzpatrick and Boulton, 1994; Kitzinger, 1995). We ran a total of six focus groups with a total of 41 participants in Berkshire, England. Two were with staff: one with probation officers and one with those professionals who work for a range of partner organisations. We ran a further four groups with individuals on probation: three with men and one with women. One of the groups with men and the group with women took place in their residential hostel. The other two groups with men took place on their community service work placement. Groups were held in private areas or rooms to ensure confidentiality. All participants were given an information sheet and those who wished to participate gave written consent. Participants were assured of confidentiality and anonymity, subject to the proviso that we were required to report to the probation service disclosures of intention to self-harm, harm another or if child protection concerns were raised. Ethics approval was granted by the University of Oxford’s Research Ethics Committee and the conduct conformed to the principles embodied in the Declaration of Helsinki. Data collection In each focus group, two researchers (E.P. and A.P.) used a semi-structured guide which aimed to explore the probationers’ perceptions of the health problems of probation and their experiences of healthcare services and recommendations for service development. The questions are shown in Box 1. The researchers explored staff perceptions of probationers’ health issues and how these needs might be addressed. Each group comprised between three and ten individuals (see Table I) and lasted between 30 and 75 minutes. The two researchers facilitated each group. The discussions were recorded electronically and then transcribed. Analysis NVivo 7 was used to facilitate analysis. We adopted a thematic analytical framework and used an inductive approach to identify themes related to our overall broad study objectives (Braun and Clarke, 2006). Our analysis was driven by a detailed semantic description of gathered data and not by pre-conceived theories. Two researchers (A.P. and E.P.) independently coded and analysed the data. After familiarising ourselves with the data, we categorised and collated major themes and sub-themes to form patterns within the data. We also examined the data for deviant cases and then reviewed and discussed their interpretations, resolving the few minor differences that emerged as coding progressed.
Box 1: Questions asked during the interviews ’
What would you say are the sorts of health problems people on probation might have?
’
Who has used the health services since being on probation this time? Which ones?
’
From your experience, we want you to identify the good things about the services that you have used recently and the bad things.
’
Please could each person say one way in which they would improve health services?
Table I Composition of focus groups
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Focus group
Location
1. 2. 3. 4. 5. 6.
Probation hostel At work Probation hostel Probation premises Probation premises At work
Probationers Probationers Probationers Professionals: partner organisations Professionals: probation officers Probationers
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Number of participants
Gender
Age range
6 3 7 9 10 6
Male Male Female Mixed Mixed Male
31-60 19-60 21-59 33-58 28-54 22-58
Findings Health: a low priority Most participants had a clear idea of the various health problems encountered by individuals on probation. Both staff and the probationers alike were able to identify a number of key health concerns. However, both those on probation and the groups of professionals identified that health was not a priority issue for probationers. They had much more pressing concerns. These might be finding employment or appropriate housing, or for those with ongoing alcohol and drug problems, meeting the needs of their addiction: Bottom of the pile. It’s the last thing they want to do [y] get yourself a balanced diet and a goodnight’s sleep! (Focus group 4). I don’t know much about health, but you see some people who die like instantly like heart attack, run over by buses, so in a way I reckon you just should be like yourself and not worry too much about health and like that. (Focus group 2).
The stress of being on probation Despite the fact that health and a healthy lifestyle were a low priority, the probationers themselves were able to identify a range of health concerns. The most important health concern, identified by all groups, was the stress caused by being on probation. As one probationer succinctly noted, “I think stress and strain is the biggest health issue”. All groups identified a number of reasons why being on probation was so stressful although the specific reasons varied from focus to focus group; they appeared to depend on where the individual was placed. However, a key theme was the power of the probation officers; probationers felt they were at the mercy of their probation officer who used their professional position to threaten rather than support them: I’ve been out 11 months and I can’t think of one single thing my probation officer has done for me. Me neither Me neither – no I got a CSCS [construction skills certification scheme] card (general murmurings of agreement) I was out two weeks before I saw my probation officer. He was too busy to come and visit me! I could do whatever I wanted. There’s no sort of building a foundation to start with – finding a job or employment or housing. (Focus group 1). We’re just guinea pigs aren’t we? My probation officer (I really don’t like her) and she’s stopping me seeing my mum and my family so it feels like she’s setting me up to go back to prison. We are like guinea pigs; they can do what they like to us. It’s not fair. (Focus group 3).
What they wanted from their probation officer was someone to help them move forward, help them address their needs such as housing and employment. However, the majority felt that they did not do that. They were slow to provide the information they required yet quick to threaten them with the prospect of returning to prison. They found that the control probation officers exerted over them to be a source of considerable stress: They don’t try to help you They don’t put you in touch with the people who are going to help you. Or sign you to them [y] they don’t do that. (Focus group 1). [Probation officers] they stress you out even more [y] you done a crime, right, but they should talk to you about the positives. You want to turn back the hand of time, right? But you can’t. They keep asking you the question about the past [y]. (Focus group 2).
Although the majority of the men found their probation officers less than helpful, there was some disagreement in the women’s group. Some women found their probation officer helpful although others were quick to identify problems with theirs. All these women were located within a hostel and had established positive relationships with the hostel staff. This was in marked contrast to the men’s hostel where residents perceived staff to be unhelpful and cited occasions when their
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actions had been dangerous. One resident identified the time when they had given him too much of his prescribed medication and another described an occasion earlier in the year when they had neglected the health needs of a drug using resident who was subsequently found dead in his room. Many felt that a range of other health problems were directly attributable to the stress they experienced including depression, smoking and substance use: Alleviating stress – that’s drugs and drink [y]. There’s a lot of stress in here, a lot of stress. You want to change, you want to get your life back on track and then people in here think they know and telling you to do things they think will be good for you – the stress! If you drag on a fag, it calms you down a bit, doesn’t it? I never smoked in jail but here! (Focus group 1).
Prison or probation? All groups talked about the differences between prison and being on probation. There was a general consensus amongst the men that prison was preferable and that things there were “easier” as they were provided with shelter and meals three times a day. There was also more certainty: the provision of information was standardised through induction programmes and individuals knew what they should be doing at a given time. Furthermore, it was much simpler to access a range of health services as these were obviously located within the prison: I’d rather be in prison than here but I suffer this for my family. I’d love to be in a prison cell right now. Knowing what I’m gonna do. Knowing everything’s gonna be alright [y]. (Focus group 1). I wish I didn’t have to do this. But it goes back to consequences. You could get paid for this. A lot of people they prefer to go to jail but if you got paid for this [y] they’re like ‘it’s so easy to go to jail.’ (Focus group 2).
This was also acknowledged by the professionals: I think what is striking sometimes is that quite a lot is people in the community who can’t cope with addressing their addiction like to go to prison. ‘I want to go to prison – that is the only place I can get clean’. And HMP Detox is sort of like that is what they see really. I can get clean in prison, can come out and start again, and I think that is quite a sad place to be really. That is actually a combination of accessing service, but also about their motivation. They are forced to do it. It is a lot easier somehow to address it while you are in custody. (Focus group 4).
The women on probation had a different view and considered being in the hostel preferable to being in prison. However, one woman who had experience of another hostel could see that whether or not prison appeared preferable depended very much on where you were located when on probation. She had a lot of praise for her current placement where she felt safe and supported and was alcohol and drug free, but she had previously been in another, very different hostel: Here you learn slowly how to integrate into the community. [In prison] you’re safe but so institutionalized [y] [Last time I came out of prison] I did find it hard to integrate. I did manage to get to a hostel but it wasn’t all female, there were lots of drugs going around, lots of alcohol. They didn’t force me to fail but I wish I’d had the support what I’ve got now [here] then maybe I wouldn’t have ended up in prison again [y] The other hostel was completely different. I didn’t feel safe there where here I feel safe and, I have the support [y] The staff here is really nice. (Focus group 3).
Mental health and substance use In addition to stress and depression, smoking and substance use related to this stress, those on probation also recognised a range of other health issues. Alcohol and substance use and mental health issues were recognised as considerable problems in themselves. Alcohol was a particular concern. It was seen as socially acceptable, widely advertised and easily accessible. However, whilst the substance itself was easily accessible, this was not the case with appropriate services and support for those with alcohol problems as participants in the FGD below discuss: From my point as an alcoholic, more support for alcoholics [is needed]. Not just detox and then thrown out on the street again [y] You have more support as a drug addict than an alcoholic. There’s just not enough support fullstop. Considering how many people it kills [y] They’ve stopped all
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the cigarette advertising but alcohol – phaff! Every TV series you watch they’re down the pub, commercials, billboards, everywhere. It’s available – everywhere! If you’re an alcoholic you get given your antabuse whatever to get off of it but it’s the actual support afterwards because it whether you do the detox you still got it in your head mentally that you want the alcohol not something that’ll block it. And I know it takes willpower as well but it would be good if there was something they could give you that stopped the urge, the feeling. And it’s so easily available [y]. When you get the urges you need the support. It’s definitely something that’s lacking in the NHS. It’s not the detox as I have been [y] they detox in three days and then you’re out and there’s an off license round the corner! I had immense support in rehab [y] I’ve got a lot of support here. The NHS need to step up [treatment of alcohol]. (Focus group 3).
Mental health issues were also a concern, again because many people with depression felt their needs were not being met. These participants explained: Depression is a big issue [y] it’s what got me here. People [with depression] are put to the side and then something serious happens so they think they’ll do something now but it’s too late [y] when it comes down to mental health it shouldn’t be the case [that there’s a crisis]. If you really need support it’s not there. Then you end up self harming, trying to commit suicide or a crime against someone else, seriously hurt someone else like I did [y]. I asked for help, I was crying out for help, but I wasn’t given it. (Focus group 3).
The lack of appropriate and timely mental health services were also raised by the professionals. They felt, as did the probationers themselves, that services in the community were not sufficiently comprehensive and people were allowed to “fall though the gaps”. This meant that the community mental health crisis team were not willing to intervene or help until a crisis point was reached. Only if the crisis had resulted in an offence, they would then be identified by the local court diversion team and fast tracked into mental health services as appropriate. At other times, the probation officers themselves were simply left to manage the individual as best they could despite their lack of mental health training: The crisis team has services, but it is very much about, we get an offender phone up say they are gonna kill themselves, if they have been working with them for a while, they are just like, ‘look the guy has personality disorder, and they do this all the time.’ But, we are dealing with someone who goes in crying for help, and even if they have no intention of killing themselves, it is pretty desperate to be even saying that, and it needs assessment by a health professional at that stage. Offenders will call up their offender managers even if they don’t have appointments specifically to disclose that, ‘I am feeling so low, I am feeling suicidal.’ (audible agreement by other participants) Or they will call up and say, ‘please can you phone up the police’ and ‘I don’t want them to find my body when there are maggots in my mouth’ [y] Then you have to try deal with that conversation, and if you’re dealing with mental health services, they are like – yeah, this person does this all the time. But you are sort of struck with what do I do with that? (Focus group 5).
The professionals identified a number of other areas of mental health provision which they felt were lacking. There was a lack of services for people with personality disorders and these individuals comprised a substantial proportion of their caseload. Similarly they felt the services for those with learning disabilities were lacking in terms of identification and on-going support. In addition there was a lack of talking therapies for people with anxiety and depression, which they identified as being considerable health concerns amongst their client group.
Discussion Both probationers and professionals identified a range of health issues. They largely agreed about the key issues which included substance use and mental health problems. However, the most important issue for probationers was dealing with the stress of being on probation. This was not generally recognised by professionals, who were identified as being part of the problem by probationers. All participants recognised the impact of issues such as housing, finances and employment on the wellbeing of probationers and were concerned about the lack of access to health services, in particular mental health services and comprehensive alcohol services, and how this affected probationers’ health.
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Participants in this study identified mental health and substance use as key issues and this is in line with health surveys of probationers that have quantified this problem (Mair and May, 1997; Brooker et al., 2009; Ryan et al., 2005; Crilly et al., 2009; Abdul Pari et al., 2012). However, it was concerning that these were areas where health service provision was considered to be particularly deficient by staff and probationers alike. Furthermore, it was concerning that individuals whose crimes were not attributed to any mental illness were neither considered to be at risk of mental health issues nor offered any support for “less severe mental disorders” such as depression or personality disorders. Despite the recent emphasis on mentally ill offenders (Bradley, 2009) and the apparent success, at least locally, of court diversion schemes, these findings suggest more needs to be done “upstream”. There is a need to engage these individuals earlier in effective treatment and thus perhaps prevent them from re-offending at all. Improved continuity of care from prison to the community may be an area for further investigation. Alcohol use is a significant concern for many probationers and there was a perception that effective services are lacking. The high prevalence of alcohol use in probationers has been reported elsewhere (Abdul Pari et al., 2012; Brooker et al., 2009; Solomon and Silvestri, 2008) and clearly the important challenge locally is the development of accessible services for these individuals which will provide not simply the drug treatments for detox but longer term counselling and support services. It will be important to determine what impact these services have not just on the health of probationers but on re-offending rates too. Given the well-established links between alcohol consumption and crime (Graham et al., 2012), effective services are likely to have a beneficial impact on re-offending. It was notable that the male probationers saw prison as an easier way of serving their sentence than being on probation. They could see the advantages of the routine, the three times meals a day, and the easy access to healthcare. This is perhaps surprising: institutionalisation is not usually seen as a good thing. Indeed the Oxford English Dictionary definition of institutionalized is “Of a person: confined to an institution. By extension, usually of a long-term patient or prisoner: adversely affected, esp. made apathetic or dependent, by prolonged institutional confinement” (Oxford English Dictionary, 2013). This definition suggests that it is a negative experience. Goffman (1968), who wrote extensively on the failings of institutions, noted over 40 years ago that “There are certain bodily comforts significant to the individual that tend to be lost upon entrance into a total institution – for example, a soft bed or quietness at night”. However, the male probationers in this study could see the advantages of being in prison, highlighting “bodily comforts” that were available to them. This is an area that would be worth exploring with further research. This study has highlighted some key areas for health service development and will inform the planning of services for this group of individuals in the local community. It is the first time such a study has been conducted in this geographical area and provides useful information not only for health services but also the probation service itself and their partners. It has added to the evidence base on the health of probationers, a largely neglected group; paradoxically more is known about the health of the 88,000 prisoners in England and Wales although there are 230,000 offenders in the community. As noted in the introduction, the NHS in England is currently undergoing major reform with CCGs taking responsibility for commissioning services for the local community, including probationers (National Health Service Commissioning Board, 2013). CCGs would become part of local community safety partnerships (CSP) and contribute to the strategic needs assessment of crime, anti-social behaviour, re-offending and substance abuse for their defined CSP areas (Health and Social Care Act, 2012). While, the extent to which CCGs are involved and their role in shaping delivery of high-quality care for probationers is still unclear, this change creates an opportunity to develop services for this hitherto neglected group. However, with considerable public service cuts, there is also a risk that these vulnerable individuals are forgotten. We would echo Brooker et al.’s (2012) assertion that there is a need for a national study of the prevalence of mental health disorders in probation populations in the UK and suggest that such a study should look beyond mental health to include a full range of health issues and associated costs. Without this information, the magnitude of the problem will remain poorly documented and therefore more likely to be ignored by local commissioners and national policy makers. Furthermore, we
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should examine models of care in other countries, such as the USA, where there are similar challenges (Lurigio, 2011). Although the qualitative methods used were appropriate for the study question, and the participants’ accounts were credible with considerable agreement between staff and probationers, further validation of the findings should ideally have been undertaken. Resource and time constraints meant that the researchers were not able to present the findings to participants for verification. Nor, given that we did not aim to obtain a sample representative of all probationers, are the findings widely generalisable. However, we wanted to gain the views of a broad range of key groups of probationers (those in post release hostels and those on community service) and of professionals. We were able to achieve this and, despite the heterogeneous groups and the small sizes, the themes identified from analysis of the data were remarkably consistent.
Conclusions Improving the health of offenders on probation is not only important for the offenders, but also for their friends, family and wider community. Identifying and effectively addressing probationers’ health needs is likely to have major impact on decreasing their burden of illness, particularly mental disorders and alcohol related problems, while reducing re-offending. The challenge remains for local health service commissioners and providers and the probation service to work together at this time of organisational change in the NHS and the probation service in order to provide appropriate and accessible services for all those on probation.
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Herinckx, H.A. and Swart, S.C. (2005), “Rearrest and linkage to mental health services among clients of the Clark County mental health court program”, Psychiatric Services, Vol. 56 No. 7, pp. 853-7. Kitzinger, J. (1995), “Qualitative research: introducing focus groups”, BMJ, Vol. 311 No. 7000, pp. 299-302. Lurigio, A. (2011), “People with serious mental illness in the criminal justice system: causes, consequences and correctives”, The Prison Journal, Vol. 9 No. 3, pp. 66S-B6S. McNiel, D.E. and Binder, R. (2007), “Effectiveness of a mental health court in reducing criminal recidivism and violence”, American Journal of Psychiatry, Vol. 164 No. 9, pp. 1395-403. Mair, G. and May, C. (1997), Offenders on Probation, Home Office, London. Ministry of Justice (2013), Offender Management Statistics Quarterly Bulletin, Ministry of Justice Statistics Bulletin, London, July-September 2012. National Health Service Commissioning Board (2013), “Commissioning development”, available at: www. commissioningboard.nhs.uk/ourwork/com-dev/ (accessed 28 February 2013). Oser, C.B., Leukefeld, C.G. and Tindall, M.S. (2006), “Male and female rural probationers: HIV risk behaviors and knowledge”, AIDS Care, Vol. 18 No. 4, pp. 339-44. Oxford English Dictionary (2013), Oxford English Dictionary, Oxford University Press, Oxford, available at: www.oed.com/view/Entry/252092 (accessed 23 April 2013). Ryan, T., Hatfield, B. and Downing, B. (2005), “A follow up-study of probation service-approved premises residents in contact with mental health services”, Journal of Forensic Psychiatry & Psychology, Vol. 16 No. 4, pp. 699-713. Sirdifield, C. (2012), “The prevalence of mental health disorders amongst offenders on probation: a literature review”, J Ment Health, Vol. 21 No. 5, pp. 485-98. Solomon, E. and Silvestri, A. (2008), Community Sentences Digest, Centre for Crime and Justice Studies, King’s College London, London.
Corresponding author Dr Emma Plugge can be contacted at: [email protected]
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