An Evaluation of Staffordshire and Stoke on Trent Partnership NHS Trust s Anxiety Management Programme (AMP) at HMP Stafford Executive Summary Prepared by Dr Martin Glynn and Professor Laura Serrant The Centre for Health and Social Care Improvement School of Health and Wellbeing University of Wolverhampton Room ML110 ML Building Deanery Row Off Molineux Street Wolverhampton WV11DT
Aknowledgements: I would like to thank; Professor Laura Serrant for supervision and guidance throughout the course of this evaluation; Johanne Tomlinson the founder of HMP Stafford s Anxiety Management Programme,, for her constant support throughout; Dr Hazel Mackay & Janice Lovatt from the Staffordshire and Stoke on Trent Partnership-NHS Trust for additional support; representatives of the Staffordshire and Stoke on Trent Partnership-NHS Trust for their engagement and cooperation during the evaluation; the staff of HMP Stafford who ensured I was well looked after during my time whilst working in the prison; and finally the participants HMP Stafford s Anxiety Management Programme, past and present, who were not only supportive but without their openness, honesty, and continuous engagement throughout, this evaluation would not have been possible. The content and findings of this evaluation do not reflect the views of the Staffordshire and Stoke on Trent Partnership, NHS Trust, or those of HMP Stafford.
Principal Investigator: Professor Laura Serrant, Director of Research and Enterprise from CHSCI in the School of Health and Wellbeing, University of Wolverhampton. Research Assistant: Dr Martin Glynn, Honorary Research Fellow from CHSCI in the School of Health and Wellbeing, University of Wolverhampton.
Anxiety Management Programme (AMP) at HMP Stafford It helps prisoners to realise that they are not the only one s suffering and that there are others in similar circumstances where you can learn and cope with, these anxiety issues. It also helps them to change their lifestyles by using the coping skills and adjusting the way they deal with issues. Inmates say that the course has changed their lives. They also gain the back control of their lives. It also empowers them to deal with issues and concerns in a controlled way without having to self-harm or used prescribed medication. Self harmers become men who do not have to self harm for pressure release. Senior Officer HMP Stafford The men feel supported, taken seriously, and the help on how to manage anxieties has a positive impact on their behaviour on the wings. They deal with incarceration and the frustrations of imprisonment & cell sharing in a more appropriate way, leading to less build-up of anxieties. Officer HMP Stafford It s an extra tool to help address and develop the individual s feelings and prevents anxiety coming out as anger and aggression. This alleviates potential conflict or even self-harm. Men in general bottle their emotions and feelings up and they find it quite difficult to let go. This course allows the individual to realise that they can let their guard down and slowly try to talk about things without embarrassment and fear of retribution from peers. Angela Parton - Supervising Officer HMP Stafford It is often the first stage of addressing the barriers to resettlement and reducing offending behaviour. It enables them to accept the causes and provides strategies for dealing with their emotions which in turn has a profound effect on behaviour which is seen as disruptive. Claud Lofters - Deputy Governor HMP Stafford It addresses the unmet needs of a high percentage of prisoners who are suffering from longstanding high anxiety levels. It empowers them to enhance their day to day functioning, promotes hope. It also has a positive impact on family life and relationships. Carol Briggs Registered Mental Health Nurse HMP Stafford It allows clients to understand what anxiety is and how it affects the individual. It allows the client to deal with their personal levels of anxiety. It gives them coping strategies to overcome the effects of their anxieties. Stewart Westwood Drug and Alcohol Services HMP Stafford Enables prisoners to develop personal coping strategies in dealing with various anxious situations. Broadens their understanding into why they respond and behave in certain situations. Equips them with a set of tools in emotional well-being. Benjamin Hayemeyer RGN HMP Stafford
Strategic Contexts 1 1.1 National Context: Home Office (2013) argue that more needs to be done to provide more rehabilitation services for offenders returning back to their communities. They further argue that too many offenders, go through the justice system, serve their sentence and simply pick up where they left off, (2013:7). Central to the Government s assertion is in the development of services that will support offenders to overcome the barriers that prevent them from turning their lives around. Therefore, as mental well-being is acknowledged as a mitigating factor that can impede an offender s capacity to not re-offend, it is timely to investigate the scope of nurse led offender health interventions as a possible way forward. Home Office (2013) cite 5 key outcomes they aim to achieve in an attempt to improve the current rehabilitation landscape: 1. Greater flexibility An encouragement for providers to use more innovative means to address rehabilitation. 2. Extend the scope of rehabilitation Service providers should aim to reach more offenders than currently exists, with short terms offenders being a priority. 3. More Efficient services New and improved services should be targeted to those with the most need. 4. Greater Diversity of Providers To expand the current probation remit to include private, voluntary, and community providers. 5. Collaboration with partners Strategic partnerships on a local level. 1.2 Regional Context: Similarly, the Staffordshire and Stoke on Trent Partnership, NHS Trust, (2012-13) cite the need for evidence-based quality services that is not only driven by structures and processes, but more importantly, people. They further cite Nurse Johanne Tomlinson s work in setting up HMP Stafford s Anxiety Management Programme as a best practice example of success, and what is possible by working in partnership with a local prison.
This would suggest that a nurse led offender healthcare pathway not only satisfies the Government s new strategic vision, but it may provide some enhanced local strategic opportunities that would greatly assist existing criminal justice aims in reducing reoffending and improving offender well-being, and in turn tackle some of the wider social determinants of health for offenders as a whole. 2
3 Executive Summary 1.3 The Evaluation 1.3.1 The privileging of the participants voices, stories, insights, and understandings were the key feature throughout the evaluation. 1.3.2 This evaluation has been conducted as a partnership between The University of Wolverhampton, Centre for Health and Social Care Improvement (CHSCI), HMP Stafford, and the Staffordshire and Stoke on Trent Partnership, NHS Trust. It was in response to a call from the Burdett Trust for Nursing which is part of a three year project whose key objective is: Improving Health and Wellbeing for Offenders through Nurse-Led academically Driven Community Interventions. 1.3.3 The data collection and analysis used the Silences Framework, (Serrant-Green 2011), which provided the theoretical context for researching/evaluating the health care needs of marginalised populations such as offenders. 1.3.4 To access the personal stories of participants in line with the silences framework ; non participant observation, focus group discussions, interviews, participants own reflective accounts were used to gather the data. 1.3.5 HMP Stafford s Anxiety Management Programme was set up with the following key objectives: To provide a structured anxiety management programme of support and education tailored to suit the needs of service users. To utilise evidence gained from the anxiety management group to develop a predictive tool for us in other settings. To expand the service into other prisons and related services. 1.3.6 The key evaluation questions were: What are the critical factors that make a nurse led programme such as AMP effective and impacting in the lives of the participants? What impact does the programme have on the desistance trajectory and personal appraisal of wellbeing whilst in prison? How does this impact assist re-entry back into the community? How will the programme assist the participants in building social capital capacity whilst in prison?
4 1.3.7 To locate HMP Stafford s Anxiety Management Programme within a wider strategic context in relation to Staffordshire and Stoke on Trent NHS partnership requires further investigation to consider new possibilities explore wider implications, and possible challenges, both regionally and nationally. 1.4 Participants: 1.4.1 Anxiety disorders for the participants on the Anxiety Management Programme were diverse, complex, and common. 1.4.2 Anxiety disorders such as; childhood trauma, personal circumstances, contact with the criminal justice system, the impact of incarceration, fear of release, re-entry, and reintegration back into society, led some participants to feel a continuous sense of loss, hopelessness, and despair. 1.4.3 Unaddressed anxiety disorders developed whilst in prison; depression, suicidal thoughts, delusions, poor self-concept, low self-esteem, poor coping skills, personal isolation, diminishing health, and numerous fears related to release, led many participants to project negative thoughts, feelings, and behaviours, onto other prisoners, staff, and the regime in general. 1.4.4 The majority of participants found the design and delivery of the anxiety management programme, beneficial, helpful, and empowering. 1.4.5. There was a marked increase in participant s confidence, behaviour, and coping skills whilst in prison, as a consequence of participating in the anxiety management programme. 1.4.6. Overwhelmingly, participants expressed the view that a nurse led anxiety management programme was significantly more beneficial and impacting than other related support services in HMP Stafford. 1.4.7 Most participants felt that HMP Stafford s anxiety management programme should be rolled out in other sectors outside of the prison, with specific reference to schools and related youth services. 1.4.8 Most of the participants felt frustrated at not having any through care provision regarding their anxiety disorders post-release.
5 1.4.9 Several participants highlighted the vulnerability at the lack of sustainability and resourcing of the anxiety management programme. 1.5 The Programme: 1.5.1 The size and scope of the evaluation meant that it was not possible to ascertain the full extent of anxiety disorders in HMP Stafford. 1.5.2 Many participants had developed anxiety disorders over a period of many years, which placed a strain on their capacity to seek help, guidance, and support whilst in prison. 1.5.3 Referral pathways for access to the anxiety management programme tended to be informal, exposing the need for a more structured approach to marketing and promotion of the programme within the regime as a whole. 1.5.4 The anxiety management programme has numerous benefits; managing prison life, addressing criminal behaviours, preparation for release, and desistance readiness, which is beneficial for the regime as a whole. 1.5.5 The absence of a continuity of care (post release) in relation to the anxiety management programme reduces the gaining of much needed contemporary awareness in assessing the wider impact on the participant s well-being, building of social capital, and ultimately their desistance trajectories. 1.6 Conclusions 1.6.1 For many prisoners suffering from anxiety in HMP Stafford, a nurse led intervention proved to be beneficial on many levels. 1.6.2 The challenge of returning offenders is much more than their physical relocation back into their home communities. 1.6.3 Anxiety disorders can erode an offender s positive self-concept, which can lead to disconnection from friends, family, other prisoners, and in some cases the prison regime itself.
6 1.6.4 If offenders suffering from anxiety disorders are to transcend the negative impacts of their condition, they must seek transformative spaces where the interrogation of the obstacles and barriers they face is given voice, complete with the development of a personal strategy for meaningful and productive change. 1.6.5 Addressing anxiety disorders as part of an offenders desistance readiness can assist in aiding a successful return to their families and in turn the communities from which they come from. 1.7 Recommendations Nurse led Interventions 1.7.1 Nurse led anxiety management programmes should be recognised as an adapted form of motivational interviewing (Rollnick & Miller, 1995) that should form part of a wider integrated health and wellbeing strategy for offender health and wellbeing as a whole. 1.7.1.1 Investigations into how nurse led anxiety disorder interventions can inform elements of the desistance trajectory for offenders whilst in prison, and post release must be on-going and sustainable. 1.7.1.2 Nurse led anxiety management programmes must be placed in other contexts and settings outside of the prison to explore its wider applications and possibilities. 1.7.1.3 Nurse led anxiety management programmes should be embedded within prison regimes as well as presenting key strategic opportunities in relation to offender health and wellbeing provision as a whole. Strategic Development 1.7.2 There needs to be a greater recognition of the importance of addressing anxiety management all at stages of the criminal justice system, so that the processes associated with re-entry and subsequent desistance trajectories will not be derailed. 1.7.3 More investigation into anxiety disorders; impacts, solutions, management, regime and wider strategic implications, for prisoners serving long sentences is required.
7 1.7.4 Consideration should be given in looking into the possibility of how HMP Stafford s anxiety management programme can be continued post-release for both returning offenders, as well as other relevant and appropriate situations, contexts, and sectors. Future Directions 1.7.5 Academically driven partnerships can provide a robust evidence based approach and a complimentary support to strategic agencies conducting external evaluations in relation to offender health that will generate both strategic impact. 1.7.5.1 Researchers and other related professionals must call upon the offenders expert patient insights and understandings of their anxiety disorders, psychological impacts of incarceration, and their health and wellbeing as a whole when conducting research and evaluations. 1.7.5.2 More research needs to be undertaken in understanding how addressing anxiety disorders can support desistance readiness during incarceration and post release. 1.7.5.3 Future research into anxiety disorders with offenders should locate any outcomes with the wider insights and understandings of social determinants of health and to assess the implications for offender health as a whole. Future Service Design 1.7.6 Past and present participants should be engaged in a continuous dialogue in relation to the design and shaping of services that are targeted towards them. 1.7.7 Any future service designs addressing anxiety disorders and other related offender health concerns should employ the use of logic models in creating robust and rigorous frameworks.