Recent Submissions

  • Delays in transferring patients from prisons to secure psychiatric hospitals: An international systematic review

    Sales, Christian P.; Tully, John (2023)
    BACKGROUND: Transfer to a psychiatric hospital of prisoners who need inpatient treatment for a mental disorder is an important part of prison healthcare in the UK. It is an essential factor in ensuring the principle of equivalence in the treatment of prisoners. In England and Wales, delays in transferring unwell prisoners to hospital were identified by the 2009 Bradley Report. There has been no subsequent systematic review of progress in so doing nor a corresponding appraisal of transfer arrangements in other parts of the world. AIM: To conduct a systematic review of international literature about transfers of mentally unwell individuals from prison to hospital for the treatment of mental disorder since 2009. METHOD(S): Eight databases were searched for data-based publications using terms for prison and transfer to hospital from 1 January 2009 to 4 August 2022. Inclusion criteria limited transfer to arrangements for pre-trial and sentenced prisoners going to a health service hospital, excluding hospital orders made on the conclusion of criminal hearing. RESULT(S): In England, four articles were identified, all showing that transfer times remain considerably longer than the national targets of 14 days (range, 14 days to >9 months); one study from Scotland found shorter mean transfer times, but more patients had been transferred to psychiatric intensive care units than to secure forensic hospitals. There were only two studies that investigated prison to hospital transfers for mental disorder from outside the UK and only one reported time-to-transfer data. CONCLUSION(S): Findings from this literature review highlight failures to resolve transfer delays in England and provide little evidence about the problem elsewhere. Given the lack of data, it is unclear whether other countries do not have this problem or simply that there has been no research interest in it. A possible confounding factor here is that, in some countries, all treatment for prisoners' mental disorders occurs in prison. However, the principle that prisons are not hospitals seems important when people need inpatient care. Prospective, longitudinal cohort studies are urgently needed to map transfer times and outcomes. Copyright © 2023 John Wiley & Sons Ltd.
  • Six nations: A clinical scenario comparison of systems for prisoners with psychosis in Australia, Bolivia and four European nations

    Barlow, Stephan (2022)
    This paper compares across six nations the mental health systems available to prisoners with the highest acuity of psychosis and risk combined with the lowest level of insight into the need for treatment. Variations were observed within and between nations. Findings highlight the likely impact of factors such as mental health legislation and the prison mental health workforce on a nation's ability to deliver timely and effective treatment close to home for prisoners who lack capacity to consent to treatment for their severe mental illness. The potential benefits of addressing the resulting inequalities are noted. Copyright © The Author(s), 2022. Published by Cambridge University Press on behalf of the Royal College of Psychiatrists.
  • Impact evaluation and economic benefit analysis of a domestic violence and abuse UK police intervention

    Kane, Eddie (2023)
    This study evaluated the impact and economic benefit of Cautioning and Relationship Abuse (CARA), an intervention which aims to reduce re-offending of first-time low-level domestic violence and abuse perpetrators. The analysis was based on two samples drawn from separate UK police force areas. CARA’s impact was assessed using a matched sample of similar offenders from a time when CARA was not available. The matching was based on a host of offender and victim characteristics and machine learning methods were employed. The results show that the CARA intervention has a significant impact on the amount of recidivism but no significant reduction in the severity of the crimes. The benefit-cost ratio in both police force areas is greater than one and estimated to be 2.75 and 11.1, respectively, across the two police force areas. Thus, for each pound (£) invested in CARA, there is an economic benefit of 2.75–11.1 pounds, annually.
  • Developing a trauma-sensitive, compassion focused substance misuse treatment intervention for prisoners

    Fehrman, Elaine (2022)
    The aim of this paper is to present a newly developed substance misuse treatment intervention, which has been devised from an extensive review of the literature relating to the prevalence and repercussions of trauma amongst people who use forensic services and use substances. The clinical utility and applicability of integrating Compassion Focused Therapy (CFT) within the context of delivering this new intervention is discussed. As the first pilot is preparing to launch at a high secure site, this paper provides a descriptive, theoretical account of the programme and the rationale for the various components.
  • Knife crime offender characteristics and interventions – A systematic review

    Green, Kathleen (2022)
    Knives and sharp objects are tools used in a wide range of violent offences. However, knife offending may have different risk factors than general violence, thus requiring tailored interventions. This systematic review aims to synthesise evidence on the characteristics of knife offenders and interventions aimed at the reduction of knife crime. After screening 1352 titles and abstracts, 344 articles were fully considered of which 21 papers met the inclusion criteria and were quality assessed. These consisted of 15 offender characteristic studies and six intervention studies. Findings suggested that knife crime may be associated with illicit drug use, exposure to any violence as a witness, victim or perpetrator and mental health problems. Males were more at risk of engaging in knife crime in the community and females in domestic settings. Different risk factors were found between gang involved and non-involved knife offenders. Primary prevention strategies, such as stop and search, knife amnesties, media campaigns and curfews did not show a significant impact in reducing knife crime. By contrast, increasing offenders' access to tailored support regarding housing, education, and employment showed an impact in reducing weapon carrying. Further research is required in the area to support the reliability of outcomes.
  • Me-thinking: report on a pilot intervention with women in custody

    Gois, Isabel; Kane, Eddie (2022)
    Purpose This pilot study aims to assess the feasibility of conducting shared philosophical inquiry with women at risk of re-offending to improve motivation to change. The philosophy sessions aimed to give participants new ways to think about their lives and to help them have more control over their own mind by learning new ways to think differently. Design/methodology/approach The pilot study adopted a mixed-methods approach to collect and analyse data pre- and post-intervention. Ten women serving a custodial sentence at the Democratic Therapeutic Community (DTC) in HMP Send were recruited to take part in ten weekly sessions of philosophical discussion. The intervention was adjunctive and not meant to replace other treatments an inmate may already be receiving. Findings The results showed that most participants experienced improved levels of well-being and mental health post-intervention, and that the intervention has the potential to help participants better critically assess their own behaviour and ways of thinking. It also suggested that the intervention has the potential to help participants engage more effectively with the therapeutic process. Research limitations/implications The results of this study are limited by the small sample size and the lack of a control group. As such this study cannot rule out that the changes observed in participants were a function of time or the specific therapeutic environment they were in (or both). Originality/value This pilot study is innovative not just for introducing philosophy classes to the women’s prison estate for the first time in England and Wales, but also in its ambition to contribute to the “what works” agenda in offender rehabilitation.
  • Evidence-based policing and community crime prevention

    Kane, Eddie (2021)
    This book addresses and reviews progress in a major innovative development within police work known as evidence-based policing. It involves a significant extension and strengthening of links between research and practice and is directed to the task of increasing police effectiveness in the field of community crime prevention. This volume provides an international perspective that synthesizes recent research results from the United States and other countries – including systematic reviews of large bodies of evidence – to illuminate several of the most challenging issues currently confronting police departments. It examines recent advances in research-based models of policing and the expanding base in outcome evaluation. Key areas of coverage include: Managing the nighttime economy; Supervising sex offenders; Tackling domestic/intimate partner violence; Addressing school violence and the formation of gangs; Reducing victim and witness retraction and disengagement; Responding to mental disorders, safeguarding vulnerable adults, and providing victim support; and Leveraging public awareness campaigns. In addition, each chapter presents an overview of key issues within a designated area, synthesizes existing reviews, and examines the most recent research. The book clearly and concisely presents major concepts, theories, and research findings, thereby providing both conceptual and analytic tools alongside an integrated presentation of principal findings and messages. The volume concludes with a discussion of current directions in research, key developments in policing strategies, and identification of effective operational structures for facilitating and sustaining research-practice links. (PsycInfo Database Record (c) 2022 APA, all rights reserved) (Source: cover)
  • Providing social care following release from prison: Emerging practice arrangements further to the introduction of the 2014 Care Act

    Challis, David (2022)
    Although prisoners have significant care needs and are particularly vulnerable following release, there have been longstanding concerns about their social care. Among its provisions, the 2014 Care Act defined the responsibilities of local authorities for identifying and meeting the social care needs of prisoners. Here, we report the findings of a national survey of local authorities undertaken in 2016, which explored the early arrangements put in place following the Care Act for prisoners on release. Eighty-eight of
  • Investment v impact in policing and mental health: What works for police and suspects

    Kane, Eddie (2020)
    Police officers' encounters with people experiencing mental health (MH) problems can be particularly challenging for both parties. For many people with MH issues, these encounters are influenced by having previously had a negative experience with the police or fear of being blamed or not believed because they have MH problems. Research into the impact of police interactions at the arrest and initial detention points in the criminal justice process reveals a mix of sometimes-conflicting findings. Related studies have shown that police interventions involving individuals with mental health issues and suspected of minor offences are more likely to lead to these individuals being arrested. This chapter discusses the current interventions and investments in England. The most common interventions used in England at the health and justice interface, including contact with police officers, are Liaison and Diversion, embedded staff in police Command and Control Rooms (CCRs), Street Triage (ST) as an extension of police CCR and ST provided as a separate service. The chapter also discusses the evidence for effectiveness and return on investment of current interventions, positive impacts of current interventions and investments in England, and the evidence for effectiveness, cost benefit and return on investment of Crisis Intervention Team. (PsycInfo Database Record (c) 2021 APA, all rights reserved) (Source: create)
  • The older prisoner health and social care assessment and plan (OHSCAP) versus treatment as usual: a randomised controlled

    Challis, David (2021)
    Background: Older people are the fastest-growing demographic group among prisoners in England and Wales and they have complex health and social care needs. Their care is frequently ad hoc and uncoordinated. No previous research has explored how to identify and appropriately address the needs of older adults in prison. We hypothesised that the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) would significantly increase the proportion of met health and social care needs 3 months after prison entry, compared to treatment as usual (TAU). Methods: The study was a parallel randomised controlled trial (RCT) recruiting male prisoners aged 50 and over from 10 prisons in northern England. Participants received the OHSCAP or TAU. A clinical trials unit used minimisation with a random element as the allocation procedure. Data analysis was conducted blind to allocation status. The intervention group had their needs assessed using the OHSCAP tool and care plans were devised; processes that lasted approximately 30 min in total per prisoner. TAU included the standard prison health assessment and care. The intention to treat principle was followed. The trial was registered with the UK Clinical Research Network Portfolio (ISRCTN ID: 11841493) and was closed on 30 November 2016. Results: Data were collected between 28 January 2014 and 06 April 2016. Two hundred and forty nine older prisoners were assigned TAU of which 32 transferred prison; 12 were released; 2 withdrew and 1 was deemed unsafe to interview. Two hundred and fifty three 3 prisoners were assigned the OHSCAP of which 33 transferred prison; 11 were released; 6 withdrew and 1 was deemed unsafe to interview. Consequently, data from 202 participants were analysed in each of the two groups. There were no significant differences in the number of unmet needs as measured by the Camberwell Assessment of Needs – Forensic Short Version (CANFOR-S). The mean number of unmet needs for the OHSCAP group at follow-up was 2.03 (SD = 2.07) and 2.06 (SD = 2.11) for the TAU group (mean difference = 0.088; 95% CI − 0.276 to 0.449, p = 0.621). No adverse events were reported. Conclusion: The OHSCAP was fundamentally not implemented as planned, partly due to the national prison staffing crisis that ensued during the study period. Therefore, those receiving the OHSCAP did not experience improved outcomes compared to those who received TAU.
  • Screening male prisoners for depression and anxiety with the PHQ-9 and GAD-7 at NHS HealthchecK: patterns of symptoms and caseness threshold

    Packham, Chris; Williams, Marie; Kaul, Adarsh; Morriss, Richard K. (2021)
    BACKGROUNDScreening for depression and anxiety disorders has been proposed in prison populations but little is known about caseness thresholds on commonly used self-report measures in relation to core symptoms, risk factors and symptom patterns.METHODA cross-sectional prevalence survey measured depression and anxiety caseness (threshold scores > 10 and > 15 on PHQ-9 and GAD-7 and diagnostic algorithm on PHQ-9) in 1205 male prisoners aged 35-74 years eligible for an NHS Healthcheck from six English prisons. Caseness scores were compared with the presence or absence of daily core symptoms of depression and generalised anxiety disorder (GAD), demographic, prison and cardiovascular risk factors. Cluster analysis was applied to PHQ-9 and GAD-7 items in prisoners scoring > 10 on PHQ-9.RESULTS453(37.6%) and 249(20.7%) prisoners scored > 10 and > 15 respectively on PHQ-9; 216 (17.9%) had a depressive episode on the PHQ-9 algorithm; 378(31.4%) and 217(18.0%) scored > 10 and > 15 on GAD-7 respectively. Daily core items for depression were scored in 232(56.2%) and 139(74.3%) prisoners reaching > 10 and > 15 respectively on PHQ-9; daily core anxiety items in 282(74.9%) and 179(96.3%) reaching > 10 and > 15 on GAD-7. Young age, prison and previous high alcohol intake were associated with > 15 on the PHQ-9. Cluster analysis showed a cluster with core symptoms of depression, slowness, restlessness, suicidality, poor concentration, irritability or fear. Altered appetite, poor sleep, lack of energy, guilt or worthlessness belonged to other clusters and may not be indicative of depression.CONCLUSIONSIn male prisoners > 35 years, a score of > 10 on the PHQ-9 over diagnoses depressive episodes but a score of > 10 on the GAD-7 may detect cases of GAD more efficiently. Further research utilising standardised psychiatric interviews is required to determine whether the diagnostic algorithm, a higher cut-off on the PHQ-9 or the profile of symptoms on the PHQ-9 and GAD-7 used singly or in combination may be used to screen depressive episodes efficiently in prisoners.
  • A day as a prison paramedic

    Hodgett, Rachel (2021)
    In this second instalment of Paramedic Roles, Rachel Hodgett shares what a day in the life of a prison paramedic looks like, alongside what led her there, and the job's unique challenges and rewards.
  • NHS Health Check Programme: a qualitative study of prison experience

    Williams, Marie; Thomson, Louise; Butcher, Elizabeth; Morriss, Richard K.; Packham, Chris (2020)
    BACKGROUND: NHS Health Checks began in England in 2009 and were subsequently introduced into English prisons. Uptake has been patchy and there is limited understanding about factors that may limit or enhance uptake in prison settings. Uptake of this programme is a key policy in reducing the risk of cardiovascular disease and death in these settings. METHOD: Semi-structured focus groups were conducted with groups of prisoners (attendees and non-attendees to the health check), prison healthcare staff, custodial staff and ex-prisoners (n = 50). Participants were asked about their awareness and experiences of the NHS Health Check Programme in prison. RESULTS: All groups highlighted barriers for not attending a health check appointment, such as poor accessibility to the healthcare department, stigma and fear. The majority of participants expressed a lack of awareness and discussed common misconceptions regarding the health check programme. Methods of increasing the uptake of health checks through group-based approaches and accessibility to healthcare were suggested. CONCLUSIONS: This study reports on prisoner, staff and ex-prisoner perspectives on the implementation of NHS Health Checks within a restrictive prison environment. These findings have potentially substantial implications for successful delivery of care within offender healthcare services.
  • Are Liaison and Diversion interventions in policing delivering the planned input: A longitudinal evaluation in two constabularies?

    Kane, Eddie (2020)
    Liaison and Diversion (L&D) has twin objectives: improving mental health outcomes and reducing re-offending. Early diversion from police custody seems promising, but evidence of benefit is required to sustain such programmes. To test the hypothesis that contact with L&D services while in police custody would lead to improved mental health outcomes and a reduction in type and level of offending, we used a pre-post service use design. National Health Service (NHS) records in two counties were searched for evidence that patients had been involved with L&D services while in police custody during the period July 2009-December 2017. We defined January 2009-July 2014 as the pre-intervention period and any time after contact as the post-intervention period. Data from the Police National Computer were gathered for each period for these individuals, to assess their pre-post L&D contact offending histories. NHS Trust data were similarly gathered to assess their pre-post use of mental health legislation. 4,462 individuals were identified who had used L&D services in police custody. There were statistically significant reductions in the amount of offending following contact with the L&D service (whether one or two contacts), regardless of offence type. Statistically significant reductions were also observed in use of the four most commonly used legislative powers for detaining patients in hospital on mental disorder grounds, regardless of offending status (prolific/non-prolific). Our results indicate positive associations between the L&D interventions and change in offending and use of compulsory hospital detention. Whilst our research does not allow a direct causal relationship to be established in either area, the findings go beyond other impact assessments of L&D which have either been with small samples or relied only on qualitative data or expert opinion.
  • Dementia and mild cognitive impairment in prisoners aged over 50 years in England and Wales: a mixed-methods study

    Challis, David (2020)
    Background: People aged ≥ 50 years constitute the fastest-growing group in the prison population of England and Wales. This population has complex health and social care needs. There is currently no national strategy to guide the development of the many-faceted services required for this vulnerable population; therefore, prisons are responding to the issue with a range of local initiatives that are untested and often susceptible to failure if they are not fully embedded in and securely funded as part of commissioned services. Objectives: The objectives were to establish the prevalence of dementia and mild cognitive impairment in prisoners in England and Wales and their health and social care needs; validate the six-item cognitive impairment test for routine use in prisons to aid early and consistent identification of older prisoners with possible dementia or mild cognitive impairment; identify gaps in current service provision; understand the first-hand experiences of prisoners living with dementia and mild cognitive impairment; develop a care pathway for prisoners with dementia and mild cognitive impairment; develop dementia and mild cognitive impairment training packages for staff and prisoners; and produce health economic costings for the care pathway and training packages. Design: This was a mixed-methods study. Setting: The study setting was prisons in England and Wales. Participants: Prisoners aged ≥ 50 years and multiagency staff working in prison discipline and health and social care services took part. Results: Quantitative research estimated that the prevalence rate of suspected dementia and mild cognitive impairment in the prison population of England and Wales is 8%. This equates to 1090 individuals. Only two people (3%) in our sample had a relevant diagnosis in their health-care notes, suggesting current under-recognition of these conditions. The prevalence rate in prisons was approximately two times higher among individuals aged 60–69 years and four times higher among those aged ≥ 70 years than among those in the same age groups living in the community. The Montreal Cognitive Assessment screening test was found to be more effective than the six-item cognitive impairment test assessment in the older prisoner population. Qualitative research determined that staff and prisoners lacked training in knowledge and awareness of dementia and mild cognitive impairment, and this leads to problematic behaviour being viewed as a disciplinary issue rather than a health issue. Local initiatives to improve the lives of prisoners with dementia and mild cognitive impairment are often disadvantaged by not being part of commissioned services, making them difficult to sustain. Multidisciplinary working is hampered by agencies continuing to work in silos, with inadequate communication across professional boundaries. A step-by-step care pathway for prisoners with dementia and mild cognitive impairment was developed, and two tiers of training materials were produced for staff and prisoners. Limitations: Our prevalence rate was based on the results of a standardised assessment tool, rather than on clinical diagnosis by a mental health professional, and therefore it may represent an overestimation. Furthermore, we were unable to distinguish subcategories of dementia. We were also unable to distinguish between a likely diagnosis of dementia and other conditions presenting with mild cognitive impairment, including learning disability, severe depression and hearing impairment. Questionnaires regarding current service provision were collected over an extended period of time, so they do not reflect a ‘snapshot’ of service provision at a particular point. Conclusions: We hypothesise that implementing the step-by-step care pathway and the training resources developed in this study will improve the care of older prisoners with dementia and mild cognitive impairment. Future work: The care pathway and training materials should be evaluated in situ. Alternatives to prison for those with dementia or mild cognitive impairment should be developed and evaluated. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 27. See the NIHR Journals Library website for further project information.
  • Cardiovascular risk profiles and the uptake of the NHS Healthcheck programme in male prisoners in six UK prisons: An observational cross-sectional study

    Packham, Chris; Butcher, Elizabeth; Williams, Marie; Morriss, Richard K. (2020)
    INTRODUCTIONHalf of all deaths in custody are due to natural causes, the most common being cardiovascular disease (CVD). National Health Service Healthchecks should be available to all eligible prisoners; it is not clear who receives them. Mental health issues are common in prisoners and may affect how healthcare interventions should be delivered. Current policy is to offer Healthchecks to those serving over 2 years in prison.OBJECTIVES, METHODS, SETTING AND DESIGNAn observational cross-sectional survey in six male prisons in England between September 2017 and January 2019 in prisoners aged 35-74 to identify who was eligible for a Healthcheck and compare CVD risk data with those that were not, and factors associated with uptake.OUTCOME MEASURESCharacteristics of those accepting a Healthcheck were compared with those declining. Assessments of anxiety and depression were compared with CVD risk factors.RESULTS1207 prisoners completed a Healthcheck. 21.8% of prisoners were ineligible due to existing comorbidities. 76.4% of those invited took up a Healthcheck, and of those, 12.1% were found to have new significant CVD comorbidity. CVD risk was similar to community levels but this population was 10 years younger. Definite case-level depression or anxiety was present in 20.7% and 18.0%, respectively, of participants. An association was found between ethnicity and those invited (p=0.023, φ=0.1) and accepting (p=0.008, φ=0.1) a Healthcheck. 9.7% of prisoners serving less than 2 years had CVD risk scores of 10% or more, and had similar CVD risk profiles but much higher levels of anxiety (p<0.001, φ=0.2) or depression (p=0.009, φ=0.2) than those serving 2 years or more.CONCLUSIONCardiovascular risk was comparable with community rates and in some prisons, much higher. Rates of anxiety and depression were high. The national policy for selecting prisoners for Healthchecks may leave many high-risk prisoners without appropriate cardiovascular preventative assessments.
  • Prison vs. hospital for offenders with psychosis; effects on reoffending

    Huband, Nick; Haque, Quasi; Duggan, Conor (2019)
    With research showing a high prevalence of psychosis in prisons, its effective management is essential for clinical and criminal outcomes. In a matched sample of released prisoners and discharged patients with psychosis (124 pairs) we investigated whether group participation (prison vs. hospital) affected the likelihood of reoffending as well as time to reoffending. Statistical analysis was completed using multilevel logistic regression and multilevel survival analysis. We found that prison cases were more likely to commit any offence within a given period of time (1, 2 or 3 years). Moreover, at any particular time 3 times as many patients with psychosis released from prisons reoffended proportionally to their matched controls discharged from hospitals (HR = 2.92, 95% CI = 1.99, 42,9, P < 0.001). In conclusion, release from prison carries higher risk of a future offending and reduced time to reoffending among offenders with psychosis. Notwithstanding limitations inherent in observational study designs, we renovate that in addition to clinical need and the humanitarian argument, offenders with psychosis should be treated in secure hospitals to reduce future recidivism.
  • Clinical and ethical challenges in undertaking LIMPRINT in vulnerable populations

    Bussey, Rachel; Whiston, Siobhan (2019)
    Background and Study Objective: To estimate the prevalence of chronic edema (CO) and wounds within two vulnerable populations, a male high security prison in the East Midlands (United Kingdom) and residential and nursing homes in the United Kingdom and Australia. Methods and Results: Methods for screening for CO and wounds were adapted from the main LIMPRINT methodology. Prison Population: In total, 195 inmates were recruited with 22 (11%) having CO. While the majority were white Caucasian (156/83.4%) a further 20 (10.7%) were dark skinned with 11 (5.95%) from other minority populations. Comorbidities included 123 (63%) smokers, 22 (11%) alcohol dependant, 60 (31%) with mental health problems, and 35 (18%) a history of self-harm. Only three had a current wound with 30 (16%) having had a traumatic stab wound. Residential and Nursing Homes (United Kingdom and Australia): In the United Kingdom, the total population available for inclusion was 189 with only 137 (73%) recruited. Seventy-two of the 137 (52%) suffered from CO and a further 16 (23%) had a history of cellulitis. Results from the Australian residential care facilities have been published in full. In summary, of the 37 participants 20 (54%) experienced CO with 25 (68%) having comorbidities and 11 (30%) having a concurrent wound. Conclusion: Obtaining an accurate picture of the prevalence and impact of CO in vulnerable populations is extremely challenging due to issues of access and consent. Lack of reliable data for these populations will contribute to poor service provision.
  • Effectiveness of current policing-related mental health interventions: A systematic review

    Kane, Eddie; Shokraneh, Farhad (2017)
    There are three commonly used mental health interventions associated with policing: liaison and diversion, street triage and having specialist staff embedded in police contact control rooms. Crisis intervention teams (CITs), already used in the USA, are now attracting wider interest, including in the UK. Investment in these interventions is growing, so it is important to have evidence of their effectiveness.
  • Serving a community sentence with a mental health treatment requirement: Offenders' perspectives

    Samele, Chiara (2018)
    Background: Safe alternatives to custody for offenders with mental disorder are vital, not least as self-harm, and violence rates are rising among them in prisons. In England and Wales, the Criminal Justice Act 2003 allows a mental health treatment requirement (MHTR) to supplement a community or suspended prison sentence, but this combination is poorly understood and rarely sought. Aim: To explore offenders' perspectives on the MHTR. Methods: We interviewed all 25 consenting offenders under an MHTR in two probation areas. Verbatim transcripts of their audio-taped narratives were analysed using grounded theory methods. Results: Their core concern was "instability," characterised by many health and social difficulties and resolved by achieving stability, which included not reoffending as well as becoming healthy, substance free, and "having a life." Most considered that the MHTR helped their motivation and service provision, but some cited poor supervisor accessibility, supervisor role confusion, and sense of stigma under the order as stressful and threatening good outcomes. Conclusions: This first account of offenders' perspectives on the MHTR suggests a model in which, under it, offenders see themselves making progress as courts require. They understand the risk of return to court and imprisonment if in breach. This model of understanding how MHTRs work could provide for professional guidance and evaluation of their effectiveness. Copyright © 2018 John Wiley & Sons, Ltd.

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