It is estimated that up to 60 per cent of the UK’s male prison population has a brain injury, with many also carrying histories of trauma, childhood abuse and drug and alcohol misuse.
NR Times speaks to St Andrew’s Healthcare consultant psychiatrist Dr Shahzad Alikhan and consultant clinical psychologist Dr Lorraine Childs about the importance of specialist forensic neuropsychiatric services like Rose and the challenges facing an underserved community.
“In brain injury, every patient is different, and it can depend on which part of the brain has been affected, by what mechanism and how severely,” Dr Alikhan explains. Dr Alikhan acts as a responsible clinician for patients detained under the Mental Health Act.
“Our first step is to assess the patient and develop a treatment model based on their individual needs.
“In many cases, there are problems with communication and comprehension, which can be associated with an increased risk of aggression or violence.”
Patients are either transferred onto Rose from other St Andrew’s wards or external facilities such as prisons and psychiatric intensive care units (PICUs).
Many bring with them complex histories and patterns of aggressive behaviour.
Studies suggest that between three and six times as many young offenders report having suffered a brain injury as in the wider population.
Dr Childs discussed the backgrounds and behaviours of the brain injury community within forensic services, explaining how brain injury can exacerbate premorbid antisocial personality traits and behaviours.
“After a brain injury, you can lose the ability to think outside of yourself, so you become very self-focused.
“Wondering about how someone else is feeling or if they’re hurt is quite complex and may conflict with your own needs. So people with a brain injury can lose empathy, become more disinhibited and risky towards others.
“They can also have more problems looking at themselves and their environment, as well as communication and comprehension issues, which can be very frustrating and also contribute to an aggressive response.”
Dr Childs’ also said that past literature and her own clinical observations suggested that, compared to the rest of the forensic population, people with brain injuries in forensic services are more likely to:
- Have a diagnosis of substance/ alcohol abuse
- Have (up to 5x) higher proportions of comorbid psychiatric disorders.
- Have higher proportions of antisocial personality disorder/ psychopathy and/ or other personality disorders, including borderline and narcissistic
- Have more cognitive impairment
- Have more problems with activities for daily living
- Have more communication/ comprehension problems
- Have more physical health problems
- Are more likely to escape
- Are (up to 4x) more difficult to discharge
- Are more vulnerable in the community.
Comorbid psychiatric symptoms and complex personal histories present a significant challenge to facilities unequipped to deal with this subset of patients.
And according to Dr Childs’, 75 per cent of those admitted to Rose, a Forensic ABI specialist service, had received no specialist ABI support until this admission, even though on average they had spent 10 years in inpatient or prison settings.
Providing a comprehensive MDT and therapeutic environment
Rose Ward provides a specialist MDT, with patients engaging in a neurorehabilitation programme, receiving feedback on their progress up to three times a day.
The treatment model also includes group sessions on social skills, communication and substance use, as well as occupational therapy.
Activities like swimming, cooking and sports are integral to the treatment model, not just to keep patients busy but also to improve brain function, Dr Alikhan explains.
“For example, swimming has been shown to strengthen connections between the brain’s hemispheres, while cooking helps with planning, organising, temperatures and timing.
“This all helps to lessen people’s risk, because their risk often comes from feeling left out, feeling aggressive, feeling different, frustrated and disabled.
“And the more you can enable someone and increase their independence, the less their risk that led to medium security would be.”
But the first step is creating the right environment, Dr Alikhan explains.
People with brain injuries can be sensitive to noise, stress, light and other stimuli, so Rose is designed to be spacious and calm, in stark contrast to prisons or more acute hospital settings.
Equally important is the team’s understanding that certain behaviours are not due to personality flaws but are often linked to brain injury.
Dr Alkhan explains: “In a prison or a non-specialist setting, things like lack of motivation, lack of engagement and inappropriate comments might just be ascribed to the person being anti-social or lazy.
“Whereas we would look at it as saying it’s because their frontal lobe doesn’t work properly, and that’s a medical issue, more so than other people might think.
“That can lead to improvements because patients actually feel understood.”
How an MDT helps patients transition into community
The MDT takes a graded exposure approach to reintegrating patients back into their community, starting with St Andrew’s’ own extensive facilities.
The expansive Northants site counts a swimming pool and outside courtyard among its facilities. Such internal spaces enable the team to see how well patients adapt to new environments, and potential risks, in a controlled setting.
Patients can then undertake supervised outings in public-facing cafes and workshops where they interact with the public, gradually building confidence as they go.
Dr Alikhan says: “We will then support them in spending a day with their family to have a meal and so forth.
“They might even go to places where there is alcohol available.
“It shows a degree of insight and self-control to be in those environments without needing alcohol, which will help them in the community and to stay well in the future.”
Patients will often arrive onto Rose from environments unconducive to brain injury rehabilitation.
But with the support of the MDT, some make rapid progress towards an eventual transition back into the community.
Dr Alikhan recalls two such cases from the past year. The first individual had been on remand in prison and, like many others with brain injury, had really struggled to cope.
The man had ended up in segregation where his brain had been deprived of input and stimulation, leading to a severe decline in mental health.
The second patient had been in a PICU, spending a lot of time in isolation.
Dr Alikhan says: “They’d both come from quite high risk, volatile environments where they’d understandably ended up in isolation, but that made things worse.
“But in both cases, the patients had had a lot of positive pre-brain injury factors. They had good family support and various other factors that were good prognostically.
“We managed to discharge one patient within six months of admission and the other within eight months, which is pretty good for a medium-secure admission.”
The key to their successful discharge was highly collaborative work, Dr Alikhan explains, and bringing more people into the process than the patient may have worked with in the past.
This included educating community teams lacking specialist knowledge about brain injury and working with them to create a supportive environment for the patient upon discharge.
Dr Alikhan says:
“All members of the team contribute their input.
“Relapse prevention plans that are adapted for brain injury by the psychologist, programmes of activity approved by an OT, and obviously the medication issues that I have more experience with.
“It’s really important to involve the community teams and our NHS and social work colleagues as well because they have a lot of information that we wouldn’t have.”
Preventing the revolving door
Recidivism is comparatively high among brain-injured patients leaving prison, a trend seen worldwide, not just in the UK.
Dr Alikhan notes that many will be released into the community without the healthy and structured environment needed to thrive.
St Andrew’s’ specialist team works with people with brain injury transferred from prisons, and if after release date, will help them to adjust to life back home.
Dr Alikhan says: “We can help the person develop their own independence through things like compensatory aids, as well as simple things like using phone alarms to remind them to take medication or attend an appointment.
“That can prevent someone from forgetting to turn up for their probation appointment because they’ve got a brain injury, and then being recalled to prison.
“Little things like that can really have massive impacts on recall to prison.
“A lot of the strategies that an ADHD coach might offer can be applicable to people with brain injuries.
“Those things can help reduce offending because they help people stay on track with goals they’ve set, usually in collaboration with their supporting teams.”
Meeting the demand for specialist services
Dr Childs’ said that there were banks of research, highlighting a need and demand for specialist forensic interventions for people with brain injury.
Such research has found that around 60 per cent of the UK’s prison population has a brain injury, equating to around 60,000 people, according to recent statistics.
However, there are only 47 available forensic beds.
Dr Childs says:
“It has been proven that if somebody’s got a brain injury, they’re more likely to be violent than someone who hasn’t got a brain injury. And about 60% of people in prison have a brain injury and cannot access standard offender treatment.
“So in my view, we need to have specialist services to cater for the significant unmet needs of these individuals.”
Click HERE to find out more about our specialist forensic neuropsychiatric service – Rose
To make a referral contact our Admissions Team on telephone 0800 434 6690 or email SAH.admissions@nhs.net
