Interview sample
We conducted 43 interviews across our three prison sites. The interviews included 15 frontline staff representing healthcare staff (n = 5), staff involved with the ACCT process (n = 6), senior operational staff on the prison wings (n = 4) and chaplaincy staff (n = 4). Eighteen prisoners were interviewed, and six meetings were recorded with the field researchers. Figure 1 summaries the model produced from the evidence to show the key barriers and facilitators to each element of the training implementation and intervention delivery. The shapes outlined by the red boundary represent the three main study aims. These were informed by three elements; the prison environment, prisoners within the prison and the staff working within each prison site. At each stage within the project barriers and facilitators were grouped together in this diagram to help summarise the findings across the qualitative interviews described below.
Stage 2: Adaptation of materials and training package
Emerging lower level themes around the adaptation of the materials and training package included the importance of adaptation through co-production, the necessary requirement to generate materials that are perceived as being relevant to the context and environment in which they were used:
‘Well, when I first got the booklet I thought, oh no, here we go again, it was another self-help style booklet. But when I’ve read it, the fact that it relates to somebody who I could associate with because they’re in a similar environment’ PRISONER
Other research has shown that this process determines its worth in whether individuals use the intervention within the system and can help to support the suggestion that failure to recognise the unique character of an organisation and its implications might limit the success in collaborating with frontline prison staff and prisoners to improve healthcare (Batalden et al., 2017).
Literacy levels within the prisoner population are poor in comparison to the general population and the booklets we produced contained a number of pictures and stories that helped to facilitate the skills we were trying to teach. One prisoner commented that the pictures were a helpful element of the booklets and facilitated them to understand the skills that were being presented: “They are good. For someone who couldn’t read and write or showing they couldn’t understand, positive, negative, just from a picture which is just simple. It was good, yes”. As such, participants felt the booklet would be suitable for ‘all sorts’ of people.
The co-production of the adaptation process also identified potential barriers, which might prevent engagement (see Fig. 1). For example, we found participants readily able to relate, define and identify problems but struggle to find solutions to their problems. One of the challenges of problem-solving in an environment where resources are necessarily constrained is that problem solving becomes necessarily reduced to ‘what can be achieved’ as opposed to what might be considered ‘an ideal’ solution. One field researcher talks about how a specifically adapted solutions list was produced as part of the booklet to help people identify potential ideas that might support how they could address their problem(s): ‘No. When, um, when we did the focus groups at one prison site we had a group of men who … some were self-harmers, some were supporters, others were just other prisoners who didn’t self-harm, and they looked at all the materials, and we asked them to generate some solutions. They could identify with all the problems we gave them, they could identify all the emotions and triggers, but they found it difficult to generate solutions’. It was important to recognise that generating solutions to a particular problem is not easy and nor uncommon. Other studies have shown that individuals who self-harm or who experience severe distress can show elements of attentional fixation (Pratt, 2015). In some cases, they may present with circumstances in which they might be experiencing problems that might not be ‘solvable’ but can be better managed to reduce the level of distress, perhaps similar to people in other situations of crisis (WHO, 2016).
This solution list subsequent formed part of the adaptation process and was used as a prompt to help people think about what options might be available to them when they perceived that ‘nothing could be done’. The process of creating the list of solutions supported the idea that having a ‘positive attitude’ to problem-solving was key to addressing their problems (see Additional file 2):
Stage 3: Training staff to deliver the problem-solving skills
The lower level emerging themes around the delivery of the training included: the experiences of receiving training whilst working in an organisation under pressure, the organisation of the training sessions themselves, the format of the training session and how the group sessions worked. This included identifying when was considered a good time to train, and an acknowledgment that problem solving in a prison might not always lead to a problem that could be ‘solved’ but the development of a technique that might help someone to cope better with the circumstances that they are having to deal with. We discuss these in more detail below.
Training in an organisation under pressure
Training people to receive new skills in an organisation and working within the constraints of the environment was challenging. During the training period the UK prison service were initiating a series of funding cuts, which resulted in a benchmarking process. In this context, the Government’s intention under the second element of its cost reduction programme was to introduce more efficient ways of working in publicly run prisons, whilst maintaining safety, decency, security and order (see https://publications.parliament.uk/pa/cm201415/cmselect/cmjust/309/30906.htm). This process led to staff redundancies, staff re-grading and staff having to re-apply for their own job. Introducing a new training initiative within this context was challenging and problematic. Many staff felt that staff shortages were prohibitive to training often citing that ‘a lack of time’ and ‘resource’ which forced them into a role which facilitated ongoing ‘crisis management’ on the prison wings: ‘Again, logistical nightmare. Erm, as it always is in the prison service. Erm, it’s dealing in crisis management’. This was also reflected in the cancellation of a handful training sessions that meant that training had to be re-arranged often on the day. One staff member refers to the nature of the working in a reactive environment and describes how things change and evolve: ‘I think the training was fine. It was awkward for you because it’s the usual story in here, we’re ever shorter and shorter of staff. You don’t need to tell me anything, I know exactly what it would be like. It would be, you expect such and such, and then such and such happens, and then this evolves and then that changes. It’s not easy.’
Organising the training sessions
The training sessions needed to be flexible and pragmatic to fit into the context of working within the prison environment and as such the research team worked in partnership with each prison site to develop a strategy for how the training could be offered and who could attend the training sessions. Although this was achieved successfully with a greater than expected uptake, the perception of how staff viewed the training became an important consideration in how the skills were subsequently utilised. For example, one member of staff talked about how training was offered in a lunchtime: ‘So we don’t … so things can be dropped at the drop of a hat, it was getting people … it were getting bums on seats were the main … were the main problem, then we tried to offer it, err, during a dinner hour, didn’t we, and, err, the enticement of, err, sandwiches … sandwiches and, erm, fizzy drinks.’
The uptake of training was generated by the use of proactive initiatives in specifically seeking out different staff groups and organisations that worked with the prison to encourage recruitment of staff to the training scheme. This worked well in conjunction with an assigned liaison person within each prison who supported the research team in the practical logistics of organising the training sessions. One field researcher recognises the importance of this contribution and highlights the need for organisational ‘buy in’, collaboration and partnership working to support to enable the facilitation of research: ‘The prison person put a lot of effort into running around for us and helping us with organising people to come to the sessions. That became almost part of that individual’s role. That individual was tasked with helping us to do this particular job. And without that we wouldn’t have managed to get as many individuals trained.’
Format of the training sessions
The format of each training session considering, who, when and where to train in each prison site was negotiated differently at each prison site and was determined by the needs and function of the prison. One prison staff member commented that ‘…to try and condense that training. I mean, we were lucky that we had fairly small groups. So, we could, we could sort of get that training moved along. If we had bigger groups, then it would have been a lot more difficult.’ The staff member recognised the importance of training in small groups. This was perceived as advantageous because the training could be facilitated in a succinct manner thus supporting the limited availability of staff time. As researchers it was important to recognise that each site was individual and the methodology used to facilitate the process needed to be sufficiently adaptable to deal with these differences whilst maintaining the integrity and fidelity to the training model. For example, one field researcher talks about how the prisons used different approaches to facilitate the delivery of the training: ‘We’ve found huge differences between the prisons. So to all intents and purposes one prison had quite an ad-hoc approach. They were very flexible though. So we trained at one site on a lunchtime. We trained in large ish groups, we trained in small numbers. I even trained individual ACCT assessors. We provided lunch. We trained on induction for staff. So that … they were very helpful in erm, providing us with, with training opportunities that were er, creative in trying to fit around their regime and supporting staff in the training.’ They continue to describe that in other prison sites the approach was different: ‘Erm, in the other prisons, they had a different approach. So they only wanted us to be in the prison and physically around in the prison as well. There was a difference to sort of the sense of us being in the prison, just around in the prison, was that they … we would only train on their lockdown sessions, which was once a month. So the pace was determined by the prison themselves.’
It became important to fit the training scheme around existing training opportunities (e.g., mandatory planned training session, whereby the prison was on ‘shut down’). It was perceived by staff to be most beneficial when the problem-solving skills training sat alongside other mandatory staff training sessions because staff were more likely to accept that it was part of their role to ‘push this forwards’. One staff member suggests that by incorporating training in this manner it could improve the receptiveness of staff to the new ideas: ‘Perfectly. I think, doing it alongside the case management training is the ideal opportunity. Because they’re the people that you’re expecting to push this forward. And as I say, some of the Senior Officers were very reluctant to sort of take on, on board, new things. Erm, because they get stuck in that routine...’. We also experienced other competing organisational changes that had perhaps hindered the implementation of the training skills. One staff member talks about how the training coincided with the introduction of the new case manager scheme:‘...it’s just bad timing. You know, they’ve focused on implementing the new case manager stuff, that’s took precedence over this, you know.’
Field researchers noted that training was affected also by the function of the prison i.e., whether it housed prisoners awaiting their sentence outcome versus those that offered prisoners a period of resettlement prior to transfer or release into the community. Such factors appeared to reflect in how staff perceived their own roles and staff retention in one prison site a member of healthcare staff reflects on the longevity of staff retention: ‘But thinking about the nursing staff you have here, I noticed at this prison their turnover of nurses when we were recruiting the nurses to do the training, people would write, I’ve been here two weeks, I’ve been here four weeks, I’ve been here six weeks. We might get eight months. I think I had one person who put, five years, but by and large, at one prison it seemed a very quick turnover. I didn’t get that impression at another prison, so I don’t know … ’. This finding suggests that training shouldn’t be perceived as a one-off opportunity but as a routine integrated programme of continued booster sessions providing new training sessions for newly employed staff and existing staff to continuously maintain or obtain new skills as employment and loss of staff change overtime.
Stage 4: Implementation of the problem-solving skills with prisoners at risk of self-harm
The research team and the staff and the prisoners who received the intervention discussed the feasibility of implementing the intervention. Through the interviews, we primarily wanted to explore why the frontline prison staff had not been able to implement the intervention as had been originally conceived and consider what might need to change so that an implementation mechanism could be used to facilitate the intervention (see Fig. 1). A field researcher recognised that: we have managed to train a large number of staff, different types of staff. But I think where we’ve hit some barriers is with regards trying to implement their skills actually in practice in some way. So you could say it is feasible to train staff. But then actually getting them to use the skills is a completely different erm area of work really’.
Delivery of the intervention was primarily promoted using a booklet with the intention of delivering the intervention within a single 30 min session. Whilst this was mainly feasible for the research team (who booked appointments for people to attend in health care) staff (particularly on the wings) suggested that they simply ‘didn’t have the time to sit with someone for this length of time’. Alternative suggestions for staff to enhance the delivery of the intervention included dividing the booklet into a series of one-page sheets which might only then take a few minutes for each sheet to be described along with some exercises for the prisoner to complete one prison member suggests:‘Maybe another thing you could have is you could have loose leaf. I’m thinking about your matrix then for something. You could say, okay, maybe this guy’s got excellent skills for … you get the prisoners who can always anticipate the problems. They’ll come up with a million and one problems, but maybe they’re not very good at working out strategies or goals or aims. So, your loose-leaf bit about actually promoting that bit and enhancing that bit. I don’t know, it’s just a thought’.
Staff found it difficult to implement the intervention particularly where the turnover of prisoners was great and previously tested and tried methods used by staff took precedence over using the new skills. One member of staff speaks of the operational running of the prison referring to the function of a local prison which had a high turn-over of prisoners providing little continuity and opportunity for them to support prisoners: Erm, I used different … well, I used my own. I’ve got my own methods and things, you know. ‘You know, err, we are a local jail, we serve the courts, we’ve got to … we’ve got to ship them out, that’s my role at the minute. Yeah, that’s the problem, yeah, that’s the only problem, we can’t … we can’t really keep hold of them or … or trap them as such.’
Engagement with the intervention and impact of the prison environment
Engagement with the intervention by prisoners was affected by different factors. One prisoner explained that he did not engage with the intervention at all, dismissing it as ‘a load of rubbish’. He explained that he only agreed to be involved in the study because he was ‘on basics’ at the time and so was confined to his cell much of the time and had many of his privileges removed. Taking part in the study was an opportunity to leave his cell. When probed, he offered reasons for his lack of engagement, including the very fact of being in prison is depressing and then being asked to look at their own depressive feelings can result in feeling more depressed, rather than helping, as he explained: When you’re in here you’re already on a downer, aren’t you? Looking at something about depression, you’re even more depressed, to be honest’.
The perception of what the intervention is about appears to play a key role in whether someone will want to engage. The personal circumstances of each individual prisoners impacted on whether they felt they had the capacity to engage with the intervention. One prisoner said:‘I’ve got a lot in my head, yeah. I’m on trial next Monday. Yeah, I’ve got a lot on, yeah. My nana’s not very well and I’m stuck in here.’ Engagement needed to be carefully timed to ensure an individual’s readiness and ability to take part in the intervention. One field researcher recognised this: Yeah, so there’s a sense that after you’ve got an opportunity, a window opportunity whether someone is going to be keen and want to engage with you and then after that, for whatever reason, they’re not prepared to come back or they’ve had enough of it or they haven’t gone any further with the booklet perhaps and we don’t see them again. I think it’s interesting for the model for future to think about the … how many sessions might be a good amount to, engage with people and what that might look like.
Some participants described the challenges associated with being in the prison environment as having ‘a central lack of control’ over the means through which they might perceive that they could resolve their problems: Yeah, you’ve got no control over them, the problems don’t go away, they just get worse and eat away at you. Until you can deal with the problem it’s still going to eat away at you, no matter if you go and look at a magazine, the problem’s still there and as soon as you’ve read the magazine that problem’s back in your head because there’s nothing to do in here. You don’t get out much so your problems are always there.’ Thus, for some participants, ‘problem solving’ implied fixing them and sorting them out but this was not possible in a prison context because prisoners have restricted freedoms which limit their ability to actively resolve their problems.
Engagement helped by prior exposure to other courses
Engagement with the skills seemed to be enhanced by prior experience of self-help courses and the prisoner’s level of self-awareness. For example, although one prisoner had recently split up with his girlfriend, he still engaged with the intervention. What appeared to enable him to engage was his capacity for self-reflection. He explained that ‘it weren’t too bad’ filling the booklet and that completing the booklet came ‘pretty easy to be honest’. ‘I think I know what my problems are kind of thing’. This response suggests that the prisoner already had a certain degree of insight into what his problems were, which made completing the booklet easier. Later in the interview, he also explained that he had ‘done Thinking Skills Programme before and some of it is similar, so it is just taking easy little steps and then trying to progress and using it to your advantage, that’s going to be a major one’.
Thus, it may be that previous exposure to similar interventions made engagement with the intervention easier as it improved this participant’s ability to self-reflect, or that participants who have higher levels of self-awareness are more likely to engage with these sorts of interventions in the first place (or both). Similarly, another participant was going through a divorce but engaged with the intervention ‘because I’ve got problems and I needed help’.
Intervention mechanisms how did it work?
The process of self-reflection changed participant’s thoughts and behaviour in a range of different ways. Overall, self-reflection and gaining insight into their problems enabled participants to manage their behaviour and cope more effectively. However, participants recounted differing degrees of success with enacting the skills that completing the booklet sought to equip them with and the intervention appeared to work in subtly different ways for each participant. Some participants seemed to gain benefits in dealing with a specific problem or issue – their narratives focused largely on explaining how a technique had helped them. One participant appeared to gain a wide range of skills and techniques from the intervention and was able to teach and support others with these skills. Finally, some participants were less secure and certain about their abilities to utilise the skills to cope with or manage problems this prisoner pinpointed that it had been the process of “working the problems out one by one” that was helpful “instead of having all the problems at once”. He used the analogy of a book to explain how working on one problem at a time had prevented him from feeling overwhelmed by his problems: ‘The best way I can describe it at the moment is, that’s a book. Each one of them chapters in the book. You’ve got to get through one problem before you can start on another one. If you try and work them all out in bits at the same time, it doesn’t work. You lose where you are. And then you end up going back to step one, which means you get emotional, you get your behavioural problems come back again. So to break it down and then go down each one.’
He explained that using this technique had enabled him to effectively prepare and deliver a presentation to a group of nine people, something he had never managed before: ‘Erm I think for most of the people I’ve seen, um, there’s been an element of introducing some sort of coping strategies in there, um, so they acknowledge that yes one, this is a problem I can sort out and I also have these other problems I can’t sort out, so I’m going to apply the coping strategies to those and just do the ones I can’. Other prisoners described using the visual imagery of putting his problems in a box and reading and watching television to enable him to relax: ‘Like I say, put the problem in the box outside your door. A visible box outside your door, put all your problems in there because you can’t get to them because the door’s locked.’
Perceived impact of the intervention on self-harm
Overall, self-harm appeared to decrease over time, but our conclusions are limited due to the lack of a comparable control group. Individual reports from those participants taking part showed 32/48 people self-harming in the 3 months prior to baseline, with only nine people reporting self-harm immediately following the intervention. One prisoner talked about how this felt:‘Since I’ve started this … this booklet and doing the bit of education, I’ve only self-harmed once: the interviewers asks: ‘Mmhmm, okay. And how much would you say you were doing it before that?, the prisoner responds: ‘About two maybe three times a week.’ I feel a lot better, because I know that if I’ve got a problem I can learn how to work through it, where before I just used to cut myself just to get rid of the pain.’
Sustainability of the intervention delivery
It was clear that using staff to implement the intervention in a highly pressured environment was not feasible. Alternative ideas about how the scheme could be implemented were discussed by prisoners one commented: ‘So perhaps that’s also an argument for extending the problem-solving training, to offer it as a class, because … you say there seems to be quite a few prisoners who are keen to use it in conjunction with their classes, in conjunction with the information desk work. But because they’ve not self-harmed they don’t have access to it. At one prison we offered the training but I think it’s a lot to expect the prisoners to come up, attend for one hour and be comfortable in using it’. Another suggested the benefit of peer support: The problem orientation worksheet, if you’ve got a mentor available to erm go through that and explain what everything means, and discuss it a little bit, then that’s...that’s great. Erm as I alluded to before, if you get someone like myself, I’d know what those meant, and I’d just tick yeah, yeah, agree or disagree.’ And also having the availability of someone (other than staff) to support on the wings ‘The booklet has been quite helpful, it’d be better if there was someone, like, to help us go through the booklet with me on the wing, when I’ve got time … .but the workers don’t seem interested in it and the staff can’t be … they haven’t got time to, but the things I’ve been doing is writing down my agreements and disagrees on that one that I’ve put down.’
Later in the interview he expanded on these comments to explain that it was not just helpful to complete the booklet he would also have liked advice and support on dealing with the problems identified through completing the booklet:‘As I say, it just needs somebody to be there if on an evening, or something, you’ve got a problem, you know someone who can go to and say, look, I’m having this problem with this, any advice on it? ‘Erm, supported by a peer mentor, which … which is fine, maybe that’s … that’s the way forward, I don’t know, but it … it did seem that like we’re being … that was just recovering stuff that we … we have already covered in the past’.