THE JURY IS OUT

The Jury Is Out Rehabilitation of Prisoners with Brain Injury

Heather Batey, managing director of brain injury rehabilitation specialist Reach, addresses the vital issue of supporting those in the criminal justice system who live with brain injury

Recently there have been a number of publications, articles and initiatives concerning the long ignored subject of historic brain injury amongst the prison population. Reach would like to congratulate The Disabilities Trust on their excellent work bringing this to the attention of decision makers and for their initiatives within the prison and probation services in England.

We would also recommend the academic review written for H.M. Inspectorate of Probation – Traumatic Brain Injury: Academic Insights (2021/09) by Hope Kent & Prof. Huw Williams as an excellent summary of the current situation.

To recap some facts –

> In the general population around 2 in 100 people have suffered a moderate to severe Traumatic Brain Injury (TBI).

In the prison population this is 15 in 100 people. > Out of a group of 58 young (15 – 18) male offenders The Disabilities Trust found 58 per cent had suffered a TBI before or at the same age as their first offence. > Of this group 54 per cent had been in custody more than once. > Brain Injuries reduce the ability to deal with emotional self-regulation and increases frustration and agitation. TBI is associated with higher levels of reaction aggression.

It is clear that the prison population has a higher level of TBI than the general population and that it plays a role in first offence and repeat offence behaviour. It is fair to conclude that brain injury influences the current size of the prison population. Amongst the general public there are some desires and expectations concerning the functioning of the judicial system which are significantly impacted by the prevalence of brain injury amongst the prison population. These ‘apple pie’ statements include: > A desire to see lower levels of crime on our streets > Fewer people in prison > Custodial sentences that reduce the likelihood of repeat offending

Verdict – It’s not going too well at present

The provision of good rehabilitation must play a role in meeting the electorate’s desire for lower levels of crime by identifying and supporting those living with TBI. The challenge will be to provide the right intervention at the right time. In this editorial I would like to make comparisons between Reach’s experience with people living with TBI in the community over the last 30 years and the challenges that will be faced when extending rehab to prisoners.

When is the right time for rehab?

It is generally agreed that a good rehabilitation programme is “The Right Rehab at the Right Time”. There are three significant points at which rehabilitation could be initiated:

Original Injury

It seems that many prisoners have suffered a significant brain injury before their first offence. This highlights the need for a rigorous approach to identifying brain injury in all A&E and doctors’ appointments and hospital admissions when there has been indication that a blow to the head might have been sustained. The causes of the injury may be RTAs, assault, sports injuries and falls, in fact anything in which the head received a blow. Identification and treatment at this early stage will almost always fall upon the NHS. You may scoff and say that improvements in treatment at this stage is ‘pie in the sky’ considering the difficulties that the NHS is working under. Reach knows from experience that brain injury frequently goes undiagnosed, especially when there are other, more obvious, physical injuries. However, the earlier rehab can be provided the better the prognosis. The challenge for the NHS is not dissimilar to that faced by the governing bodies of rugby, who have introduced simple screening protocols for any head injuries in the amateur game and a hierarchy of recommended actions. Working with a major insurance company, Reach developed its Headlight service, which is an online screening service. Headlight is currently used as a triage facility for RTA victims who may have sustained a head trauma. It identifies the relative severity of the head trauma (if present) and indicates the nature of any rehab required. It is commonly reported in many branches of medicine that receiving a formal diagnosis can be extremely beneficial to clients. It can provide reassurance, make clients more rigorous in undertaking treatment and more mindful of their symptoms. Certainly, it is our experience that providing feedback on the results is beneficial to both the clients and the funders. Being in a position to make assessments and offer assistance at the earliest possible stage could over time show significant improvements in first time offending. This would require the development of a screening tool/ questionnaire which can be easily completed and assessed, with concrete actions in the same way as Rugby has developed protocols.

Entering the judicial system

When someone is first taken into custody their background and medical history will almost certainly be unknown to the police, however difficult or threatening behaviour being displayed may stem from problems caused by an historic head trauma/injury. The use of a screening tool at this stage could help the police to be swiftly aware that there are other factors in play. As a brief aside with potential relevance to this area, it is worth mentioning that recent years have seen a plethora of data from medical research into the blood biomarkers that are present post-TBI, with a newly published study¹ reporting that the presence of certain biomarkers on the day of injury are now considered to be reliable enough indicators to aid in the decision making to recommend brain CT. While significant elevation of the biomarkers assayed in this study are short-lived, there is ongoing research into others that may yield useful diagnostic information for considerably longer periods post-injury. A 2020 study² observed ice hockey players from Sweden and the USA with Post-Concussive Syndrome (PCS) or Acute Concussion (AC) diagnoses. The results of this study showed some promise in that the presence of a particular protein in the blood, neurofilament light chain (NfL), is a positive indicator for PCS for up to 5 years post-injury. If my understanding is current (and be warned, I have wandered quite a bit from my clinical expertise here), potential confounders need to be understood before any useful test to detect the presence of serum NfL could be developed, let alone deployed in the field. However, the thought of having such a relatively cheap and portable diagnostic test that could be used in environments like police stations or prisons is an exciting prospect for a neuro-OT. In November 2021 The Disabilities Trust announced that they were rolling out a new training package to all healthcare workers within prisons and probation services. The aim of the programme is to prepare staff to work with brain injured individuals, providing tools to support service users with the complex needs associated with brain injury. This is an excellent initiative but doesn’t necessarily replace the need for the formal identification of the injury. While awaiting a court appearance or on receiving a non-custodial sentence there should be options for the provision of rehabilitation which do not have to be an intensive clinic based service. Reach have been running remote programmes for clients with PCS for several years, which is applicable to all PCS sufferers regardless of the cause or their current location. We have found remote rehabilitation delivery extremely beneficial for individuals whose work, life style or caring responsibilities make it difficult to attend routine appointments. This type of rehabilitation would be an ideal vehicle for delivering TBI education and strategies to help those with brain injuries cope with memory issues and emotional/ behavioural issues, and could be provided to those who are both within the community and the judicial system.

Custodial sentence and release

Reach has 30 years’ experience specialising in rehab for moderate to severe TBI in the client’s home and community. A major objective is to enable the individual to maximise their potential and to become as independent as possible. There are a number of significant advantages to working within the home setting as opposed to that of a residential rehab facility. These include focusing the individual on ways to cope with day to day challenges and utilising the support of family and friends. TBI sufferers benefit from the stability of a regular routine and the rehab programmes often use the development of these routines as a way of introducing coping strategies. This structure of programme has been extremely successful for clients who are at home, but how transferable could it be for those in prison? Good rehabilitation programmes start with realistic goal setting and it is undoubtedly possible to identify personal objectives with an individual even in a custodial setting. Designing rehabilitation activities which build coping strategies may be challenging, but not impossible for the therapist. The personal objectives of the individual may focus on life when they are released and practical skills, such as cooking for themselves, may be possible within the prison. Techniques to cope with memory issues may also be utilised within a prison setting however, issues associated with organisation skills will be difficult as the level of autonomy will be relatively low. As mentioned previously, TBI sufferers often benefit from having a daily routine however, the routine of prison life is imposed rather than evolved and this may be a disadvantage upon release, as they may be unable to recognise the need for, or have the skills, to develop one for themselves. This raises an important point about skills transference, in that there is a strong argument to support the need for some continuance of rehabilitation in the community for any programmes that begin within the boundaries of a prison walls. The Disabilities Trust have carried out projects in three prisons where they utilised link-workers to work 1:1 with offenders with a TBI. These link-workers had a very wide brief, covering welfare as well as brain injury specific issues. The projects were very successful for the individuals involved but highlighted the need for the provision of rehab and support more widely across the prison population.

Environmental challenges

A recent encounter with a prison healthcare worker highlighted how it can sometimes be difficult to complete welfare programmes with prisoners. For instance, in response to an incident within the prison, prisoners can be locked down for several hours, days or even weeks. On other occasions a specific prisoner may be transferred to another facility with very little notice. Any of these events make the currently utilised methods of delivery more than a little inconsistent at times, which is less than ideal in an area that demands consistent inputs to succeed. The use of the kind of remote communication tools that Reach utilises to deliver screening and therapeutic sessions have already been employed to substitute face-to-face visitation in prisons across the country through much of the pandemic, so there is no reason why certain aspects of neuro-rehabilitation therapy could not be delivered via such means. This potential to remove the prisoner’s physical location from the logistics of treatment delivery could offer a paradigm shift in the provision of such services. The rehabilitation programmes provided by Reach mainly focus on enabling the individual to function within their own homes and communities, addressing day to day issues. While in custody, the day to day issues are likely to be around interacting with other prisoners and prison staff, and dealing with regulating their own behaviour. It is an advantage when the rehab is happening at home, where the individual is surrounded by friends and family who can themselves benefit from education about dealing with brain injury. In prison, there is no real family and the community is of a very different nature. The individual will not have the advantage of close family support and a normal community to reintegrate with, but there could be substantial benefits if this education is made available for fellow prisoners, helping them to understand what can be erratic behaviour. Providing rehabilitation within the prison setting will inevitably have limitations but at some point, these prisoners will be released and return home. There they will confront similar challenges to those experienced by brain injured clients returning from hospital or residential rehab. These include fitting back into the family, the self-discipline required for returning to work, dealing with paperwork and all the other pressures that society automatically assumes an adult can deal with. Any prisoner would benefit from support with these issues but in the case of someone with a TBI, these issues are magnified through the lens of the brain injury. Ideally, a follow-up tranche of rehabilitation would be made available, focusing on the new ‘real world’ challenges.

Resources, Resources, RESOURCES!

All this support requires substantial resources, where on earth will they come from? At every stage in the process that I have described we are talking about services which are already seriously underfunded. To delve any further into that question takes us into the realm of economics and politics which is well out of the remit of a neuro-rehabilitation specialist, but one may well ponder the societal value proposition of funding such treatment. There is a commonly held belief that most of HM prisons operate a revolving door, a belief that is sadly backed up by statistics from the Ministry of Justice which consistently records re-offending rates of around 60 per cent in adults released from shorter (< 12 months) custodial sentences³. Whilst it would be a stretch to imply that all of this re-offending was due to the behavioural sequelae of an undiagnosed head trauma/brain injury, it is at least logical (if not scientific) that a majority of this re-offending is due to problem behaviour and that a proportion of this will be attributable to past head trauma. Until there is more data available to come to a reasonable hypothesis, there is plenty of room for conjecture to fill the gaping void that is the absence of consensus and enough anecdotal evidence to fuel conjecture. There is a glimmer of hope on the horizon. In December 2021 the government agreed to create a panel board to develop a cross departmental strategy for ABI. This is being co-chaired by Gillian Keegan and Chris Bryant and it completed the Call for Evidence stage in June 2022. Let us hope that, for the sake of people with ABI everywhere, this survives the current political upheavals. Reach is a specialist neuro-rehabilitation provider, offering national home-based and remote neuro-occupational therapy services to clients with minor to catastrophic acquired brain injuries.

To arrange an assessment for your client, please contact our team at info@reachpersonalinjury.com or call us on 01423 326000.

It is clear that the prison population has a higher level of TBI than the general population and that it plays a role in first offence and repeat offence behaviour. It is fair to conclude that brain injury influences the current size of the prison population.