Problem-solving training: assessing the feasibility and acceptability of delivering and evaluating a problem-solving training model for front-line prison staff and prisoners who self-harm

Co-production and adaptation of a prison-based problem-solving workbook to support the mental health of patients housed within a medium- and low-secure forensic service

INTRODUCTION

Problem-solving skills (PSS) help to provide a systematic approach to dealing with and managing complex problems. The overall aim of this study was to assess the acceptability and feasibility of developing and adapting a prison-based PSS  workbook for adults within a medium- and low-secure hospital.

METHOD

We used the Medical Research Council framework in our participatory mixed methods study incorporating an adapted survey (to identify what types of problems people experience in secure hospitals), a series of three interactive workshops (to co-produce two case study examples for a workbook) and we gathered feedback from patients and hospital staff on the acceptability and feasibility of the workbook. Data from the survey were used to inform the case study examples, and the feedback from patients and hospital staff was descriptively summarised and the results consolidated.

RESULTS

In total, 82 (51%) patients took part in the survey; 22 patients and 49 hospital staff provided feedback on the workbook. The survey results indicated that patients regularly experience problems while in the hospital. Patients reported problems relating to restrictions of freedom and boredom. The workshops produced two case studies for the workbooks, with mainly positive patient and staff feedback. More work is required to improve the visual representation of the characters in the case studies, the amount and content of the language and the mechanism of the intervention delivery.

CONCLUSION

The adaptation process proved acceptable and feasible to both patients and staff. The co-production methodology for the workbook and feedback from patients and staff was an effective way of iteratively refining the materials to ensure that they were both meaningful and acceptable to staff and patients. Subsequent work is required to develop the workbook and evaluate the feasibility of the intervention delivery, recruitment rates, uptake and adherence to the PSS using a randomised controlled trial.

PATIENT OR PUBLIC CONTRIBUTION

At each stage of the project consultation with patients and/or hospital staff was involved.

Efficiency of psychological interventions in the prevention of suicidal behavior and self-injury in penitentiary population: A systematic review

INTRODUCTION

Suicidal behavior is an important public health problem, with a high prevalence in penitentiary context. Nowadays, there is a wide variety of specific treatment programs, aimed to prevent suicidal and self-injurious behavior in incarcerated people. These programs show relative efficiency depending on the model of the psychological intervention applied. This systematic review evaluates the efficiency of suicidal and self-injurious behavior prevention programs in prisons.

METHOD

Empirical studies, evaluating prevention programs for suicidal and self-injurious behavior in penitentiary context were considered for inclusion. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) directives were followed. Studies from 1990 to 2022 were reviewed, based on the review developed by Winicov (2019) that covered the time lapse between 1990 and 2015. Articles from 2015 to 2022 were located by database research (EBSCOHost, ScienceDirect, PubMed & ProQuest).

RESULTS

44,050 potential studies were identified. Eighteen were included in this systematic review (9 studies by Winicov, 2019). 14 studies showed efficacy of intervention programs on self-injury behavior. The use of Cognitive Behavioral Therapy (CBT) reduced suicidal ideation. In addition, positive results were observed in 3 studies using third-generation therapies as an intervention.

CONCLUSIONS

Suicidal and self-injurious behavior in prison shows lower levels of incidence when specific treatment programs are applied. It's crucial to increase the evaluation in relation to the implementation of new treatment models (i.e., Dialectical Behavior Therapy - DBT, Acceptance and Commitment Therapy - ACT, Mindfulness, Functional Analytic Psychotherapy - FAP) as to better orientate prevention strategies. Further research is needed in gender sensitive interventions.

Cultural adaptation of a UK evidence-based problem-solving intervention to support Polish prisoners at risk of suicidal behaviour: a cross-sectional survey using an Ecological Validity Model

OBJECTIVE

To complete a cultural adaptation of a UK evidence-based problem-solving intervention to support Polish prisoners at risk of suicidal behaviour.

DESIGN

A cross-sectional survey participatory design using an Ecological Validity Model.

SETTING

The study was a collaboration between: the Academy of Justice, in Warsaw, the University of Lodz, two Polish prisons (ZK Raciborz and ZK Klodzko) and the University of York (UK).

METHODS

The adaptation process included an examination of the use of language, metaphors and content (ie, culturally appropriate and syntonic language), the changing of case study scenarios (relevance and acceptability) and maintenance of the theoretical underpinning of the problem-solving model (intervention comprehensibility and completeness). Four stages used: (1) a targeted demonstration for Polish prison staff, (2) a wider audit of the skills with Polish prison staff and students, (3) forward and back-translation of the adapted package, and (4) two iterative consultations with participants from stages (1) and (2) and prison officers from two Polish prisons.

PARTICIPANTS

Self-selecting volunteer participants included: targeted prison staff (n=10), prison staff from the wider Polish penitentiary system (n=39), students from the University of Lodz (n=28) and prison officers from two Polish prisons (n=12).

MAIN OUTCOMES AND MEASURES

Acceptability and feasibility of the training package, reported in a series of knowledge user surveys.

RESULTS

The recognised benefits of using the skills within the training package included: enhancing communication, reflective development, collaborative working, changing behaviour, empowering decision-making, relevance to crisis management situations and use of open-ended questions. The skills were endorsed to be used as part of future penitentiary training for prison officers in Poland.

CONCLUSIONS

The skills had widespread appeal for use across the Polish penitentiary system. The materials were deemed relevant while adhering to the comprehensibility of the intervention. Further evaluation of the intervention should be explored using a randomised controlled trial design.

Exploring the acceptability of a brief online theory-based intervention to prevent and reduce self-harm: a theoretically framed qualitative study

BACKGROUND

The volitional help sheet for self-harm equips people with the means of responding automatically to triggers for self-harm with coping strategies. Improving acceptability may be crucial to increasing effectiveness and reach. The Theoretical Framework of Acceptability (TFA) was developed to guide the assessment of intervention acceptability, but to date, no studies have applied the TFA to understand acceptability of interventions for self-harm.

AIMS

To apply the TFA to (a) explore people's experiences of a brief intervention to reduce repeat self-harm; and (b) understand the most prominent aspects of intervention acceptability, to make recommendations for intervention refinements and successful implementation.

METHOD

Sixteen semi-structured interviews were conducted with people who had previously self-harmed. The TFA informed a framework analysis in which findings were mapped onto the TFA.

RESULTS

Four TFA domains were identified that were associated with acceptability of the volitional help sheet for self-harm: affective attitude, burden, intervention coherence and perceived effectiveness. People were generally positive about using the volitional help sheet (affective attitude), understood the volitional help sheet and how it worked (intervention coherence), highlighted engagement as a motivating factor in using the volitional help sheet (perceived burden) and described how the volitional help sheet could be implemented by healthcare professionals (perceived effectiveness).

CONCLUSIONS

Further modifications could still be made, but it is hoped that this intervention provides a useful tool for individuals to construct their own personalised implementation intentions, and as part of longer-term support for preventing self-harm as delivered by healthcare professionals.

Preventing suicidal and self-Injurious behavior in correctional facilities: A systematic literature review and meta-analysis

BACKGROUND

Rates of suicide and self-harm are elevated in carceral institutions. Inmates are a vulnerable group since they are exposed to multiple risk factors. This paper critically reviews empirical research on programs to prevent suicidal and self-harmful behaviors in correctional facilities and summarizes effect sizes across studies.

METHODS

We searched PsychINFO, PubMed, IEEEXPLORE and the CRISE Documentation Centre Database to identify relevant articles published before June 2022. Inclusion criteria were: peer-reviewed and with outcome data on effectiveness of prevention activities. Two reviewers independently assessed 905 articles to determine inclusion eligibility. Quality was assessed by two independent reviewers using the Quality Assessment Tool for Quantitative Studies. Meta-analyses using random-effect models were used to pool effect sizes for each outcome. This review was conducted in accordance with PRISMA guidelines.

FINDINGS

Twenty-four of the 905 articles, published between 1980 and 2022, were included. Studies were frequently conducted in the United States (n=13; 54%) and used varying study designs; most frequently pre-post with no control group (n=9; 38%). Sample sizes and interventions varied considerably. Most were of moderate quality (n=21; 88%). On average, prevention programs in correctional facilities were effective in decreasing suicide deaths (pooled rate ratio of 0·35 [95% CI 0·23 to 0·55; p<0·001]; I²=68·01%), incidents of self-harm (pooled Hedges'g of -0·54 (95% CI: -1·03 to -0·05; p=0·031]; I²=81·34%), and suicidal ideation (pooled Hedges'g of -0·39 [95% CI: -0·65 to -0·14; p=0·003]; I²=47·09%).

INTERPRETATION

Prevention activities are effective in reducing suicide death, self-harm and suicidal ideation in correctional settings. Multicomponent programs, which include several preventive activities, seem to be most effective in reducing suicide deaths. Future evaluation studies should control for confounding variables by including control groups, having larger samples and limiting attrition. Standards for suicide prevention in jails and prisons should be included in National suicide prevention strategies.

FUNDING

None.

"I'm not alone, my story matters": Incarcerated women's perspectives on the impact and acceptability of group psychotherapy involving imaginal exposure to sexual assault memories

BACKGROUND

Although it is clear that incarcerated women need access to effective therapies for trauma sequelae, some have argued that one of the most effective treatments - exposure therapy - should not be provided in carceral settings due to the presumed lack of safety and stability making such an intervention inappropriate. Group therapy, the typical mode of intervention in prisons, has also been presumed to be unacceptable for exposure-based processing due to assumptions that hearing others' trauma narratives would be traumatizing and unhelpful to listeners. However, there is a lack of data to support either of the aforementioned assumptions. This study examined the acceptability of an exposure-based group therapy for women survivors of sexual violence who were currently incarcerated (N = 61) by asking women themselves about their experiences completing an exposure-based group therapy protocol (SHARE; Survivors Healing from Abuse: Recovery through Exposure) while incarcerated. We assessed women's reasons for enrolling in the group, satisfaction with various therapy components (e.g., exposure, skill-building) and the treatment overall, and experiences of both sharing and listening to trauma narratives using a feedback survey that included a mix of multiple-choice and open-ended questions. Treatment dropout was examined as an additional index of acceptability.

RESULTS

Treatment completion was very high (88.8%). Nearly all women who completed the group reported that they would recommend it to other incarcerated women (96.7%, with the remaining 3.3% reporting "it depends"). Qualitative results revealed overwhelmingly positive feedback about the effect of the group and indicated that sharing and listening to trauma narratives in a group setting serve discrete but dually important functions. Specifically, women almost universally experienced listening to others' trauma narratives (i.e., exposures) in the SHARE group context as helpful-making them feel less alone and normalizing their experiences. Sharing one's own story primarily provided an emotional release and/or transformation (i.e., an intrapersonal rather than interpersonal function).

CONCLUSIONS

Our findings challenge common concerns about the appropriateness of 1) prison as a context for trauma-focused treatments, including exposure and 2) sharing trauma narratives in a group setting. Unless empirical evidence demonstrating harm is uncovered, best practices for PTSD and other trauma-related sequelae-those recommended in reputable treatment guidelines and interventions like SHARE that incorporate components shown to be effective (e.g., cognitive challenging, exposure)-should be offered to incarcerated women as part of standard of care.

People in Custody With a Suicidal History: An Ideation-to-Action Perspective Involving Individuals Incarcerated in Two U.S. Jails

OBJECTIVE

Despite high suicide mortality in U.S. jails, little is known about the cognitive (ideation) and behavioral (attempt) spectrum of suicide risk in this population. Identifying factors associated with the development of suicidal ideation, as well as the translation of thoughts to acts of suicide, is important for suicide prevention.

METHOD

Using data from a cross-sectional study conducted in 2018-2019, we investigated suicidal ideation and attempt among 548 individuals incarcerated in jail in the United States. Specifically, we compared those with suicidal ideation (n = 212) to those without suicidal ideation (n = 336), as well as compared those who had experienced suicidal ideation and attempted suicide (n = 114) to those who thought about suicide without making an attempt (n = 98), on a range of sociodemographic and clinical factors.

RESULTS

Over one-third (38.7%) of participants had a history of suicidal ideation, whereas 23.3% had attempted suicide. In the adjusted analyses, a family history of suicide (OR = 2.09), drug use (OR = 2.26), social support (OR = 0.61), and self-harm (OR = 24.93) were linked to suicidal ideation. No wish to live (OR = 5.26) and interpersonal violence while intoxicated (OR = 2.41) were associated with the progression from suicidal ideation to a suicide attempt.

CONCLUSIONS

Consistent with extant theoretical and empirical work, findings suggest that factors linked to the development of suicidal cognitions differ from those underlying the progression from suicidal ideation to a (non-lethal) suicide attempt.HIGHLIGHTSSuicidal risk is particularly high among individuals who are incarcerated in jail.Factors linked to suicidal ideation differ from those underlying acts of suicide.Ideators and attempters possess a different set of targets for intervention.

The effect of a peer-led problem-support mentor intervention on self-harm and violence in prison: An interrupted time series analysis using routinely collected prison data

BACKGROUND

Levels of mental disorder, self-harm and violent behaviour are higher in prisons than in the community. The purpose of this study was to determine whether a brief peer-led problem-support mentor intervention could reduce the incidence of self-harm and violence in an English prison.

METHODS

An existing intervention was adapted using a theory of change model and eligible prisoners were trained to become problem-support mentors. Delivery of the intervention took two forms: (i) promotion of the intervention to fellow prisoners, offering support and raising awareness of the intervention but not delivering the skills and (ii) delivery of the problem-solving therapy skills to selected individual prisoners. Training and intervention adherence was measured using mentor log books. We used an Interrupted Time Series (ITS) design utilizing prison data over a 31 month period. Three ITS models and sensitivity analyses were used to address the impact across the whole prison and in the two groups by intervention delivery. Outcomes included self-harm and violent behaviour. Routine data were collected at monthly intervals 16 months pre-, 10 months during and six months post-intervention. Qualitative data measured the acceptability, feasibility, impact and sustainability of the intervention. A matched case-control study followed people after release to assess the feasibility of formal evaluation of the impact on re-offending up to 16 months.

FINDINGS

Our causal map identified that mental health and wellbeing in the prison were associated with environmental and social factors. We found a significant reduction in the incidence of self-harm for those receiving the full problem-solving therapy skills. No significant reduction was found for incidence of violent behaviour.

INTERPRETATION

Universal prison-wide strategies should consider a series of multi-level interventions to address mental health and well-being in prisons.

FUNDING

Research Champions Fund and the Economic and Social Research Council Impact Acceleration Account Fund, University of York, UK.

Implementation of a problem-solving training initiative to reduce self-harm in prisons: a qualitative perspective of prison staff, field researchers and prisoners at risk of self-harm

BACKGROUND

Social problem-solving is one technique used to help reduce incidence of self-harm. Our study evaluated the feasibility and acceptability of the adaptation and implementation of a brief Problem-Solving Training (PST) intervention to reduce self-harm in prisons.

METHODS

The process involved i) adaptation of the training materials using focus groups with prison staff and prisoners, ii) training frontline prison staff to use the skills, and iii) implementation of the skills with prisoners at risk of self-harm. Qualitative interviews were conducted with prison staff, prisoners and field researchers and were analysed using a thematic framework to produce a model of the barriers and facilitators to the process.

RESULTS

We conducted 43 interviews across three prison sites. The interviews included 19 prison staff, 18 prisoners and six field researcher meetings. The adaptation to the training and intervention materials were well received. The findings identified the need to support training using a collaborative and flexible approach. Prisoner engagement was affected by their own personal circumstances and by a range of contextual issues relating to the prison environment. Implementation of the skills by prison staff were hindered by resource constraints, the prison environment and staff attitudes.

CONCLUSIONS

We found that it was feasible to adapt an existing intervention and contextualise it within the prison environment. Although we could train large numbers of staff it was deemed unfeasible for staff to implement the problem-solving skills to prisoners at risk of self-harm. Prisoners who engaged with the intervention reported a range of benefits. Alternative implementation mechanisms to tackle the contextual barriers proposed by staff and prisoners included delivery of the intervention using an educational setting and/or use of a prisoner peer-led scheme.