CJS0007

Written evidence submitted by The Disabilities Trust

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

Introduction:

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:

• Increase women’s likelihood of coming into contact with the CJS
• Increase their risk of experiencing further victimisation 
• Hinder women’s ability to engage with rehabilitation programmes and their wider network of support3.

In accordance with the Female Offender Strategy’s aim to reduce the number of women in the CJS and deliver a better experience for those in custody, The Disabilities Trust recommends the committee consider the role of screening to facilitate the identification of a brain injury, mandatory 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. Cognitive, behavioural, and emotional symptoms can be overlooked, but nevertheless potentially life changing. Symptoms can include, but are limited to:

• poor memory,
• lack of concentration or inability to multitask,
• slowness to process information,
• poor impulse control
• risk taking behaviour
• co-morbid anxiety and depression
• fatigue or difficulty falling asleep
• lack of insight (i.e. where a person might not realise they have a problem).

Whilst the prevalence of brain injuries amongst the general population is 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:

• 33% sustained their first brain injury before committing their first offence
• 75% of women had a prior mental health diagnosis

• 96% of women at HMP/YOI Drake Hall reported they had experienced domestic abuse victimisation3

Following the publication of these distressing finding, and 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:

• 75% of women referred to the BIL had a prior mental health diagnosis
• Of those with a traumatic brain injury, 40% had a mental health diagnosis, and women with a brain injury were seven times more likely to have a mental health diagnosis compared to those without
• 61% of those with a brain injury caused by domestic violence reported having self-harmed, compared to women who reported other causes of brain injury (29%)7

The above research demonstrates the disproportionately high prevalence of brain injuries amongst women the CJS and the co-morbid complexities experienced by these women, including poor mental health and domestic abuse victimisation. As such, to further fulfil the strategies aim of improving women’s outcomes, The Disabilities Trust recommends brain injury screening and mandatory awareness training for staff to give them the confidence to identify and support women with a brain injury.

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.

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. 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 South Wales and recent impact data found significant reductions in Assessment Care in Custody and Teamwork (ACCT) care pathways and adjunctions. In addition:

• Those receiving support from our BIL were more likely to be moved on to standard or enhanced regimes
• In the three months prior to the BIL’s intervention, amongst 19 men, there were a total of 25 open ACCTs. Following just one session, this number dropped to only two open ACCTs and finally down to only one after two sessions, representing a reduction of 95%.
• In the three months prior to the BIL’s intervention, there were a total of 72 adjudications or incidents amongst men supported by the BIL. This dropped by 93% after two sessions.

Whilst the above improvements were recorded in a men’s prison, they do indicate the potential benefits of support for brain injury in the justice system. 

Brain Injury Awareness Training

The Disabilities Trust is concerned that without mandatory 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.

On 11th November 2021, in an innovative partnership with NHS England and NHS Improvement, HMPPS and UKABIF, The Disabilities Trust’s Ask, Understand and Adapt Brain Injury Awareness Training was made available to all 63,000 prison and probation staff and to all healthcare staff within prisons in England. Consisting of our ‘Invisible Me’ film, which won two Dolphin Trophies at the Cannes Corporate Media and TV Award and e-learning modules, this training enables staff to ASK about a possible brain injury, UNDERSTAND the possible consequences and causes of these injuries and ADAPT the way in which they work using practice tips and advice. 

‘Invisible Me’ shares the story of Jade, who had a life-changing stroke in prison, one of the thousands of people who have experienced prison life and return to the community with a brain injury. 

The accessibility of this training, which can be found in the CJS’s e-learning platform represents a significant step forward in supporting those working within the CJS to understand brain injury and the impact it may be having on engagement with rehabilitation and ultimately reoffending. 

Acquired Brain Injury Bill – Chris Bryant MP:

After months of campaigning from The Disabilities Trust, alongside charities such as Headway, the UK Acquired Brain Injury Forum (UKABIF), the Children’s Trust and the Child Brain Injury Trust for Chris Bryant MP’s Acquired Brain Injury (ABI) Private Members’ Bill, at the end of 2021, the Government committed to drafting a strategy on ABI to meet the needs of those with a brain injury across the UK.

This landmark Strategy will be developed by a panel co-chaired by Gillian Keegan, Minister of State for Care at the Department of Health and Social Care and Chris Bryant MP, who is also the Chair of the APPG for Acquired Brain Injury. As part of The Disabilities Trust’s response to the upcoming Call for Evidence, we will continue to campaign to ensure the impact of brain injury within the CJS, for men and women is considered and addressed.

Conclusion:

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 people with brain injury and we will continue to campaign for and provide brain injury awareness training to support practitioners working in the CJS to interact effectively with people with a brain injury.

References:

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–

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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).

January 2022