Occupational therapy in prisons - the battle to help brain injured people behind bars.
Brain injury in men, women and youngsters within the UK’s criminal justice system (CJS) is up to five times higher than in the general population  – a shocking disparity that leaves countless questions begging.
Even a moderate traumatic brain injury (TBI) can result in cognitive impairments that make coping with prison life – and, crucially, community reintegration on release – all the more difficult .
This month sees the start of UK-wide screening for all brain injury sustained through violence after two decades of work by charities exposed high rates of impaired neurocognitive functioning among prisoners .
The Royal College of Occupational Therapists (RCOT) is also stepping up to help address these needs, including the incorporation of prison occupational therapists (OTs) within the support frame of its specialist mental health forensic forum .
But can such combined efforts slow down “the revolving door” of re-offending among people with brain injuries and cut crime as a result?
Here are some of the experts and evidence saying they can…
If we get it right, we will break the cycle of the revolving door and reduce victim numbers.
Dr Ivan Pitman, The Disabilities Trust
The Disabilities Trust has devoted over 20 years, so far, trying to wake us up to the widespread prevalence of brain injury among prisoners.
Interest and funding from the UK Government has been hard to attract and sporadic during that time, despite its formal acknowledgement of the problem in 2018 .
So, when Dr Ivan Pitman, the Trust’s Consultant Clinical Neuropsychologist, questions our interest in the plight of brain injury survivors ‘inside’, it’s understandable.
Members of the free world, historically, aren’t known for their sympathy for the incarcerated.
Only recently, a survey of public knowledge and confidence in the CJS in England and Wales found 70 per cent of those surveyed think sentences are too lenient .
But the Trust is well aware it’s got its work cut out on many levels. “It’s a huge iceberg,” Ivan says, referring to the UK’s prison population during our video meeting.
“There are 86,000 prisoners currently, and we’re just working at the tip of it.
We’ve spent many years beating the drum, trying to get the right people to recognise the problem and do something about it. And we’ve done that on a shoestring.
Finally, however, in 2018, Ivan added: “There was the recognition in Parliament. That was huge.
“From thereon, we’ve been able to walk through open doors and offer help, no longer having to prove that there’s a problem.”
The Trust’s approach to prisoners with acquired brain injury (ABI) – remarkably similar to that of a neuro occupational therapist – is to support them to live to the best of their abilities through:
- Adaptations to their environment.
- Adjustments in performance demands.
- Modifying expected outcomes.
It has sent brain injury link workers to 14 prisons so far, helping to train over 2000 staff and providing intense, one-to-one support to 500 ABI survivors.
The charity has also developed BISI, a brain injury screening index comprising 11 questions that can be used to identify ABI within prisons and probation, rehabilitation, and community settings.
And, to establish a unified policy for supporting neurodiverse individuals, it’s appealing to all CJS services to:
- Ask: request the systematic screening and identification of neurodiversity throughout the CJS.
- Understand: learn to recognise the symptoms and signs of impaired neurocognitive functioning and their impact on individuals.
- Adapt: modify CJS procedures to ensure rehabilitation hits the mark.
“We sent link workers in to promote the idea of brain injury being something important to understand and recognise so that people are better managed,” Ivan said.
“Brain injury is a marker for higher needs like a higher rate of depression, anxiety, or suicidal ideation, or more frequent adjudications for misbehaviour.
“Yet many misbehave more because their needs aren’t being met at an enhanced level.
There’s a need to understand that sometimes it’s not a mental health problem or a personality disorder; maybe they are brain injured.
There could be wider, societal benefits too in adapting management and treatment interventions for brain-injured prisoners.
It’s more cost-effective, for one, according to the findings of economist Michael Parsonage of London’s Centre of Mental Health, a research and support charity working for equality in mental health practice and policy.
His analysis of TBI and offending  reveals the peak period in life for both offending and head injury is during adolescence.
The long-term cost of traumatic brain injury sustained at the average adolescent age of 15 is estimated at around £155,000 per case in the general population.
However, among young offenders, due to added ‘crime costs’ such as CJS costs and costs to victims, the TBI total rises to £345,000 per case.
The Disabilities Trust is continuing its work for offenders with ABI in collaboration with the Criminal Justice Acquired Brain Injury Interest Group (CJABIIG), an umbrella organisation focusing on brain injury issues within the CJS.
Other members include The Ministry of Justice, the UK Acquired Brain Injury Forum (UKABIF), the Child Brain Injury Trust, Headway – the brain injury association, and The British Psychological Society. 
Heading up justice
Headway – the brain injury association’s Justice Project has raised awareness of ABI within the criminal justice system since 2015.
The charity spearheaded the award-winning Brain Injury Identity Card to help make the job of identifying and appropriately supporting brain injury survivors easier for police officers and other CJS staff.
Prisoners with brain injuries are also offered the card on their release.
Headway also won an NHS England contract to deliver ABI awareness training to prisons and probation services across the country, widening the training it had already provided to police forces and other CJS services.
The charity points to persuasive findings from studies dating back to 2006 to support its concerns over the high ABI prevalence in prisons. 
If we hope for positive change in people, we cannot leave them with nothing to lose.
Deborah Murphy 
OTs on the wing
Lead Occupational Therapist Deborah Murphy and her team have been hailed as ‘unsung heroes’ for their work during ‘dire conditions and a lack of promised investment ’ at HMP Pentonville during the covid pandemic.
Deborah, who has around 25 years of experience as an OT within mental health services, heads the Category B prison’s Wellbeing Centre, an award-winning OT-led day service based in one of the wings .
The Royal College of GPs’ national award for ‘best clinical team in secure services’ came in November 2019 for the design of the day service, a model now being replicated in other UK prisons .
But Deborah herself is a conduit for change.
In a recent virtual OTalk event, ‘Exploring the purpose of OT in prisons’ , she revealed how, in 2014, while mulling over design ideas for The Wellbeing Centre, she discovered “there was almost nothing” written about OT in prisons.
“Although many are doing fantastic work in their own spheres, what we offer is largely subject to the trends of the geographical area and the motivations of the service managers in that area,” she said.
I wondered how as OTs in prisons, we might be able to build a more locally relevant knowledge base.
“Over the past 7 years, I have assertively networked with OTs across the UK and beyond in an attempt to establish whether I am developing my service along with principles consistent with other OTs.
“It has become increasingly evident that OTs in prisons are a disparate bunch, with no coherent model of practice.”
To help highlight the role of prison OTs, the RCOT’s forensic special interest group was renamed in 2020 as the Forensic Prison Forum.
A splinter group of OTs - #JBOT (justice-based OT forum) - is also up and running now. It’s not affiliated to the RCOT but welcomes all with an OT role related to the CJS.
The Royal College of Occupational Therapists has published specific guidance on the role of OTs in prisons -including a reminder that prisoners, like anyone, have the human right to health and wellbeing .
Based on research over the past two decades, the guide shows how OTs can help in prisons by:
- Working with prison services to identify and address individual risk factors and health and care needs.
- Advising on interventions to enable participation and engagement.
- Facilitating group work or assistive equipment/adaptations.
- Providing recommendations for transitional support services on release.
- Contributing to health promotion, life skills and lifestyle programmes that promote prosocial behaviour and community re-integration.
They may not understand “the rules” as they have poorer language and memory skills.
UK Government 
With growing evidence of the high ABI rates in prisons, in October 2019, the UK Government published its own guide to identifying and supporting brain injured prisoners .
It advised that these prisoners may present with:
- Problems in processing information.
- Social impairments.
- Other problems like drug use and mental health issues.
‘People with TBI can find adjusting to prison life difficult. They are more likely to self-harm, are easily led into trouble by others, liable to aggressive outbursts and breaking the rules,’ the guide adds.
‘We need routine, effective and standardised screening and assessment for TBI.
‘Ideally, screening should take place at the earliest contact.’