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RESEARCH: Amanda Howerton, Richard Byng, John Campbell, David Hess, Christabel Owens, and Peter Aitken Understanding help seeking behaviour among male offenders: qualitative interview study BMJ 2007; 334: 303 [Abstract] [Full text]

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Understanding help seeking behaviour in male offenders; a challenge

Ademola A Bello   (2 February 2007)

Prison Pay System is counterproductive

Andrew J Ashworth   (11 February 2007)

More Psycho Social interventions required

Salman A Mushtaq   (13 February 2007)

Help-seeking behaviours: similar findings in young military veterans

Lauren N van Staden, Nicola Fear, Amy Iversen, Claire French, Christopher Dandeker and Simon Wessely   (13 February 2007)

Offenders need to address their basic needs before they can focus on health

Paula J Whittaker, Jilla Burgess-Allen   (20 April 2007)

Understanding help seeking behaviour in male offenders; a challenge 2 February 2007
Ademola A Bello, SHO in psychiatry Milton Keynes NHS PCT, MK6 5NG Send response to journal: Re: Understanding help seeking behaviour in male offenders; a challenge	The study represents a spirited attempt to capture the attitudes of male offenders with respect to help seeking. It focuses on a group of offenders at risk for suicide and self harm behaviours. It particularly considers their help seeking behaviour in relation to General Practitioners and other doctors. As a former Prison Service Medical officer [Overseas] and a Senior House Officer presently in a Primary Care Trust, I've met quite a few personalities akin to those described by the author. What usually becomes glaring is their deprived backgrounds and peculiar street parlance. As society in England represents more and more of a mixture of races and cultures it is going to become extremely important to be sensitive to their perspectives and needs. I suspect that the attitudes of these male offenders represent an admixture of their resentments and a reflection of the roles thrusted on them by the larger society, doctors inclusive. I daresay their mistrust of authority figure may be a transference from their earlier experiences i.e. as children and young adults. The author rightly acknowledges that these men may have mental health issues that are unaddressed. The role of psychiatrists and Drug and Alcohol Services are pivotal in providing services to this group of people. A common finding in their history is instability in relationships which fosters mistrust. This has to be addressed in the mental health care pathway to these people; they often do better when a single, experienced keyworker is assigned to them. I've found the involvement of respected Probation Officers to be valuable. They act as good role models, and often engender trust towards other workers. This will booster the provision of helpful information and preparation for release. It will be interesting to run a pilot looking at alternative forms of mental healthcare delivery for patients with history of re offending. I wonder whether the likelyhood of their seeking help will improve if their care is more client centred. I will no doubt seek to study more of this in my next posting at Broadmoor Hospital [forensic psychiatry]. I believe that just as risk assessment issues are addressed in offender's admission to secure facilities, we need to flag up their residual strengths and protective factors. The generalisability of this study may be limited because of the diverse nature of this group of people but the message is clear; if we want offenders to seek help we need to reach out and meet them at the point of their need, providing a consistent and sensitive service to them. Competing interests: None declared
Prison Pay System is counterproductive 11 February 2007
Andrew J Ashworth, General Practitioner Davidsons Mains Medical Centre, 5 Quality Street, EDINBURGH, EH4 5BP Send response to journal: Re: Prison Pay System is counterproductive	If the mean data provided in this study represent a “typical” prisoner (Aged 30 with a 6 month sentence and 18 previous convictions of which 5 resulted in prison sentences) then it should be seen in the context of a current political crisis based on a “lack” of prison places. It would appear that our prison system is based on the premise that repeat offenders are detained until they grow out of their offending behaviour. It is difficult for a prison GP to demonstrate treating people with a criminal record in an attentive and respectful manner when custody and nursing staff are closely involved in the consultation process. Trivial gestures that might indicate respect are likely to be seen as breaches of security. Unfortunately the experience of medical services for many of these patients is limited to those provided by the prison service. Prison governors receive performance related pay based on custody objectives and so, providing the prisoner stays in jail as sentenced, it becomes irrelevant if he (or sometimes she) returns to prison the very next day. Governors' bonuses are paid to keep criminals off the street, not to use the time to change offending behaviour and improve health. In consequence, prison doctors are often seen as a necessary imposition by a society that the prison is outside, providing only opportunities to escape (for example on hospital visits). Were reductions in reoffending behaviour to be associated with reward to those in authority in our prisons medical care would have a more central role, reoffending (especially that associated with dug misuse)would reduce and we would all be better off. While NHS GPs may have a role in improving perceptions of respect and autonomy, the solutions lie with Justice Ministers who could, at a stroke, use performance related pay to facilitate rehabilitation. Prison governors would take more interest in medical care if “regular customers” reduced their incomes. Competing interests: I am company secretary of the family independent pay and benefits consultancy business. I am former chair of the BMA Civil Service Committee.
More Psycho Social interventions required 13 February 2007
Salman A Mushtaq, SHO Psychiatry Caludon Centre, CV2 2TE Send response to journal: Re: More Psycho Social interventions required	This article is a very good example of why Qualitative studies are still so important despite the fact they are ranked low in Hierarchy in Evidence Based Medicine. The study explores the factors that prevent offenders from help seeking for mental health problems. Despite the fact that public views doctors as the most trusted professionals (1), most offenders interviewed in this study did not trust their GPs, which is a thought provoking finding though not surprising. Professionals, who have worked with mentally ill offenders and victims of abuse, know that these groups of patients generally find it very difficult to express themselves and to trust other people, especially people in authority and not just their GPs. There are several reasons for that, out of which the first 3 are discussed more in detail in this article. 1- Chaotic upbringing (Abuse, Dysfunctional families, drugs and alcohol, etc) 2- General distrust 3- Stigma of Mental illness 4- Low self esteem and feelings of shame and anger (2) 5- Men are less likely to disclose traumatic experiences or to seek help. 6- Previous bad experience with a professional (3) 7- Compulsory treatment in community for mentally ill offenders. 8- Needs of this group are a lot more than just medical intervention These are just some of the factors that prevent patients from seeking help or even having a belief that help is available for their complex needs. From the services point of view another practical problem is the time available during a GP consultation which on average is 5-15 minutes. How can you expect a patient to disclose such sensitive information or to ask for help when they have low self esteem, difficulty in expressing themselves and trusting other people due to their past traumatic experiences. Patients may reveal such information and askfor help for the first time only after months of therapy. There is no single solution to address the complex issues but the basic need to increase the awareness among general population, psycho education reducing stigma, easy access to multi disciplinary agencies within/through primary care and more efficient interaction between Primary care and Specialist services, seems to be essential. Thanks to the author for a thought provoking study that should generate more debate and research. References: 1- MORI poll, RCP, 2006. 2- Predicting PTSD symptoms in victims of violent crime: J Abnorm Psychol 2000; 109; 69-73. 3- Preventing the ‘Second rape’ J Interpersonal Violence 2001; 16:1239-59. Competing interests: None declared
Help-seeking behaviours: similar findings in young military veterans 13 February 2007
Lauren N van Staden, Project Coordinator Kings College London, Denmark Hill, London, SE5 9PJ, Nicola Fear, Amy Iversen, Claire French, Christopher Dandeker and Simon Wessely Send response to journal: Re: Help-seeking behaviours: similar findings in young military veterans	Dear Editor, The recent article investigating help-seeking behaviours in young males(1) leaving prison highlights key areas in which government services need to adapt to better tackle the issues associated with vulnerable adults. A study undertaken by the King’s Centre for Military Health Research had similar findings. The study investigated the help-seeking paths of young men (n=74) leaving Colchester Military Corrective Training Centre, colloquially know as the "military prison". This study found that young veterans found it difficult to access available resettlement services for a variety of reasons including: previous bad experiences with other services’, lack of knowledge of what services were available and feelings that these services would not be able to help. Additionally, this group had high levels of mental ill health, both pre-discharge (n=61, 82%) and six months after leaving (n=39, 53%). Similar to the findings of Howerton et al.(1), only a small minority of those with mental health problems were seeking help for these problems and most preferred to use informal networks of support e.g. friends and family. Six months after leaving, only one participant with a mental health problem reported seeking help for it. Previous research has highlighted the need for early interventions among recently released prison populations, with 21% of suicides occurring in the first 28 days after release.(2) This is especially concerning as within the UK Armed Forces young Army males (under 20 years of age) have more suicides than expected when compared to the equivalent UK general population.(3) This concurs with Howerton et al.'s recommendation of service provision within prisons before release in order to create positive help-seeking experiences.(1) We therefore agree with the conclusions of Howerton et al.(1) that services need to be better targeted in order to address the needs of these more vulnerable groups. However, we would further suggest, based on our research within the UK Armed Forces that services based on less formal support networks (e.g. mentoring) may provide a more successful way to integrate vulnerable groups into resettlement services. Within our study population, 82% (n=61) said that they would have found a mentor useful in their transition from military prison into civilian life. This structure could provide “an informal relationship delivered in a formal structure” and so better mimic the chosen support networks of this vulnerable group. 1 Howerton A, Byng R, Campbell J, Hess D, Owens C, Aitken P Understanding help seeking behavior among male offenders: qualitative interview study. BMJ 334: 303 2 Pratt D, Piper M, Appleby L, Webb R, Shaw J. (2006) Suicide in Recently released prisoners: A population-based study cohort. Lancet 368: 199-23 3 DASA Open deaths and suicides in the UK Regular Armed Forces 1984 - 2005. http://www.dasa.mod.uk/publications/pdfs/suicide/suicideMar06.pdf (accessed 12/02/07) Competing interests: None declared
Offenders need to address their basic needs before they can focus on health 20 April 2007
Paula J Whittaker, Specialist Registrar Public Health GMHPU, Eccles, Manchester M30 0NJ, Jilla Burgess-Allen Send response to journal: Re: Offenders need to address their basic needs before they can focus on health	The article was a very informative peice of qualitative research. We conducted a qualitative study involving 41 in-depth interviews (27 with ex -prisoners and 14 with people working with ex-prisoners) in Stockport, exploring the health needs of ex-prisoners after release. We found that basic needs, particularly access to accommodation and employment, were overwhelmingly the most important factors affecting the health of ex- prisoners after release. The ex-prisoners we interviewed expressed that they were unable to address other aspects of their health, such as tackling drug or alcohol misuse, or their mental health problems, until these basic needs had been met. One reason offenders in this study did not seek medical help for their mental distress may be that they are simply dealing with issues lower down the Maslow hierachy of need such as basic shelter. Work is needed to try and prevent prisoners from loosing their homes and jobs during their sentence, and to ensure that all prisoners have accommodation to go to on release. Competing interests: None declared