Written evidence from The Disabilities Trust
We are a charity that works alongside people with an acquired brain injury, autism, and/or learning or physical disabilities to help them live as independently as possible. Our high-quality services across the UK support people to move forward with their lives. These include: brain injury assessment and rehabilitation centres, hospitals, care homes, supported living accommodation, care in people’s homes and a school.
We also campaign, conduct research and pilot new ideas to amplify the voices of people who can’t access our core services.
Our dedicated teams of specialists provide the individual support people need to live as full a life as possible. They work closely with those we support, their families and friends, funding authorities, housing associations and others.
Find out more at www.thedtgroup.org
Women are some of the most vulnerable within the Criminal Justice System (CJS), despite representing less than 5% of the UK’s prison population1. Over half of women in prison (53%) report having experienced domestic abuse and many have children dependent on them2. To add to this complexity, The Disabilities Trust’s research found nearly two-thirds of women in the CJS may have a traumatic brain injury (TBI), the often-hidden consequences of which could hinder women’s ability to engage with rehabilitation programmes and their wider network of support3. In response to this consultation, The Disabilities Trust recommends screening to facilitate the identification of a brain injury, brain injury awareness training to provide staff with the confidence to support women who may have experienced a brain injury and the provision of specialist support, such as a Brain Injury Linkworker.
What is a brain injury and why it is important to the CJS?
Caused by either sustaining a blow to the head, also known as a TBI (e.g. due to domestic violence, road traffic accidents or a fall) or through an illness which affects the brain (e.g. a stroke or meningitis), brain injuries can be considered a ‘hidden epidemic’ as many of its symptoms can be difficult to detect or may be misinterpreted as ‘challenging’ or ‘difficult’ behaviour. Behavioural, cognitive and emotional symptoms can be overlooked, but nevertheless potentially life changing. Symptoms can include, but are limited to:
Whilst the prevalence of brain injuries amongst the general population is considered to be between 2-36%4,5,6, research conducted by The Disabilities Trust at HMP/YOI Drake Hall found a disproportionately high number of women reported histories indicative of brain injuries at 64%. Moreover, nearly all women (96%) said their injuries were traumatic in nature, with the leading cause reported to be domestic violence (62%). The Disabilities Trust also found:
Following the publication of these distressing finding, to further understand the complex vulnerabilities faced by women in the CJS, The Trust conducted additional analyses looking at our results through a domestic abuse ‘lens’. Results showed:
The above research demonstrates the disproportionately high prevalence of brain injuries amongst the CJS and the co-morbid complexities experienced by these women, including poor mental health and domestic abuse victimisation. As such, The Disabilities Trust recommends brain injury screening and support for these individuals and awareness training for staff to give them the confidence to identify and help the women affected.
The importance of Brain Injury Screening:
Brain injury can also be considered a “hidden” disability, as many of these symptoms are difficult to detect or may be misinterpreted as ‘challenging’ or ‘difficult’ behaviour. Whilst we appreciate that the causes of criminal behaviour are multi-faceted, the behavioural, cognitive and emotional consequences of brain injury should be addressed.
The first step in any intervention is the identification of a brain injury and for this information to be recorded, so that it can be shared with others within the wider network of support and intervention.
The Brain Injury Screening Index (BISI):
The Disabilities Trust have developed the Brain Injury Screening Index (BISI), which is a free, clinically validated screening tool used to establish whether someone has sustained a brain injury. Utilised by The Trust’s Linkworker’s, it has been used as part of our Brain Injury Linkworker (BIL) Service for the assessment of over a thousand men and women in the secure estate and downloaded by over 600 professionals.
Whereas tools to identify and screen for brain injury are sometimes lengthy and complex to administer and score, the BISI is a straightforward tool, which can be used in prisons, probation services, in the community and rehabilitation settings and can be administered by practitioners of all levels.
In response to the needs of the prison regime, we have also utilised a ‘mini BISI’ as part of the mandatory induction assessment, which consists of two gateway questions. This ‘mini-BISI’ allows staff to quickly screen individuals and provide a minimal increase to the assessment duration.
Once an individual with a brain injury has been identified, personalised and therapeutic interventions to manage health, cognitive, behavioural and emotional consequences of brain injury are offered by our Linkworkers. As part of a wider remit, the BIL also provides information and supports referrals to other services for further assessment or treatment.
Brain Injury Linkworker Service and its impact:
In order to support both men and women who may have a brain injury, The Disabilities Trust has provided a Brain Injury Linkworker (BIL) Service in prisons across England and Wales. Once a brain injury has been identified, using the BISI, personalised and therapeutic interventions are offered to support individuals.
In the first study of its kind in the UK, The Disabilities Trust provided a Brain Injury Linkworker at HMP/YOI Drake Hall from 2016 to 2018 to support the women there who screened positive for a brain injury3. An independent evaluation of the BIL service, conducted by Royal Holloway, University of London detailed how the support of the BIL improved women’s mood and self-esteem, as well as enhancing their confidence and positivity. The evaluation also found that the service seemed to support women’s engagement in their sentence plan, offered practical guidance for staff working with women with a brain injury, and alleviated pressure from other service provisions (e.g. mental health)8.
“She showed me ways of remembering things like writing things down, having a notepad all the time…” (Eve)[i],8
“I did get a lot of help and I did start feeling better ...and I was managing to cope a bit more …I felt more confident after seeing her, and more positive.” (Sarah)8
“She helped me to create a weekly chart to remember my appointments and when to call home to speak to my mum…” (Olivia)8
Currently, The Disabilities Trust has two BILs operating in HMP Swansea and HMP Cardiff and recent impact data found significant reductions in Assessment Care in Custody and Teamwork (ACCT) care pathways and adjunctions. In addition:
The importance of identifying brain injury was acknowledged by Her Majesty’s Prison and Probation Service (HMPPS) with guidance on how staff can help those with TBI within the secure estate. The adjustments recommended were informed by The Disabilities Trust and include:
It also provided links to The Trust’s Tips & Tricks, a series of free resources providing helpful and clear guidance on brain injury, including how to support individuals who may have a brain injury.
Brain Injury Awareness Training
The Disabilities Trust is concerned that without regulated and dedicated training for those involved at all levels of the CJS to increase understanding and promote effective engagement with individuals who may have experienced a brain injury, knowledge of these conditions will remain poor. Moreover, the behavioural, cognitive and emotional consequences of brain injury may be misinterpreted as bad behaviour, resulting in an inability to provide the right support, at the right time.
The Disabilities Trust’s Brain Injury Awareness Training:
As part of our BIL, we also provide a 3-tiered training programme, delivered by our BIL or a Consultant Clinical Neuropsychologist. This training can also be delivered digitally, if required for ease of access.
These training programmes include:
Evidence for our Brain Injury Awareness Training:
As part of a project providing brain injury support in three localities (Wales, Thames Valley and North East) between 2017-2018, 422 staff were given brain injury awareness training, including:
Results showed 98% of staff recommended the training and 88% reported increased knowledge and understanding.
More recently, we have also provided training as part of our current BIL provision in Wales. Results showed:
• 100% of respondents thought that knowing about moderate to severe traumatic brain injury (TBI) was important for their current role
• However, only 13% had received prior training
And historically, 100% were satisfied with the course
• 100% reported their knowledge and understanding on brain injury have improved after the training
• 100% reported they would recommend the training to others
• 93% reported they would change their approach to working with individuals who had experienced a brain injury.
Research by The Disabilities Trust has illustrated the disproportionately high prevalence of brain injuries amongst women in the CJS. Without appropriate screening and support women may continue to struggle with the potentially life-long behavioural, cognitive and emotional consequences of brain injuries. Research conducted by The Disabilities Trust has indicated the positive impact of supporting those with brain injury and we will continue to campaign for and provide brain injury awareness training to support those working in the CJS to interact effectively with those with a brain injury.
1 Statistica. (2021). Prison population in the United Kingdom (UK) from 2011 to 2020, by gender (in thousands). Available at: https://www.statista.com/statistics/283475/prison-population-and-capacity-of-united-kingdom-uk-by-gender/
2 Prison Reform Trust. (n.d.). Welcome to the Women’s Programme. Available at: http://www.prisonreformtrust.org.uk/WhatWeDo/Projectsresearch/Women
3 The Disabilities Trust. (2019). Making the Link: Female Offending and Brain Injury. Available at: https://www.thedtgroup.org/media/163462/making-the-link-female-offending-and-brain-injury-final.pdf
4 Farrer, T.J. & Hedges, D.W. (2011). Prevalence of traumatic brain injury in incarcerated groups compared to the general population: a meta-analysis. Progress in Neuro-Psychopharmacology and Biological Psychiatry 35(2), 390–94. doi:10.1016/j.pnpbp. 2011.01.007
5 Ferguson, P. L., Pickelsimer, E. E., Corrigan, J. D., Boger, J., & Wald, M. (2012). Prevalence of traumatic brain injury among prisoners in South Carolina. Journal of Head Trauma Rehabilitation, 27(3), E11–E20.
6 Shiroma, E.J., Ferguson, P.L., Pickelsimer, E.E. (2010) Prevalence of traumatic brain injury in an offender population: a meta-analysis. Journal of Correctional Health Care, 16(2), 147–
7 The Disabilities Trust. (2019). The Impact of Brain Injury and Domestic Abuse: A Further Analysis. Available at: https://www.thedtgroup.org/media/163732/the-impact-of-brain-injury-and-domestic-abuse-a-further-analysis.pdf
8 Glorney, E., Jablonska, A., Wright, S., Meek, R., Hardwick, N., Williams, H. W. (2018). Brain injury Linkworker service evaluation study: technical report. Royal Holloway, University of London (as the publisher).
9 HMPPS. (2019). Traumatic brain injury in the prison population. Available at: https://www.gov.uk/guidance/traumatic-brain-injury-in-the-prison-population
[i] The names of the women featured in the quotes in this document, are not their real names and are taken from the independent evaluation conducted by Royal Holloway, University of London.