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Mental Health Promotion - how to help prisoners successfully resettle and reduce the risks of re-offending

A series of worksheets to help you create an easy-to-use, local mental health promotion resource for use by busy prison staff and prison healthcare staff.

Dr Maryanne Freer, Dr David Shiers

W O R K S H E E T 1

Contents:

Sheet 1 2 3 4 5 6 7 Worksheet title Worksheets explained Facts on mental health How much prisoners are affected by mental promotion and offending health problems and the impact on their future lives and re offending The role of mental What is mental health promotion and the health promotion in the opportunities for help through mental health support of prisoners promotion How to use the Instructions for use strategically and for worksheets individual staff: with examples of use Prisoners' mental health Training aide stories The mental health Tool to help you decide which mental health promotion grid promotion areas to work on The mental health Tool to collect your local, mental health promotion consultation telephone/web contacts prompt card Description

Special acknowledgments to:

Dr Dave Tomson as co-author of the original North East Region Mental Health Promotion Toolkit Staff and prisoners of HMP Drake Hall, Staffordshire for their help and ideas in developing these worksheets David Williams Offender Health and Social Care lead for CSIP West Midlands

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Mental Health Promotion worksheets explained

Why is mental health important to prison staff?

Mental health is a key factor in re-offending and indeed a huge number of prisoners have mental health difficulties. These include problems like depression, anxiety, stress, loss reactions, substance misuse, and can result in self harm, attempted and sometimes completed suicide. Prisoner mental health is an important contributor to the stresses of the job of prison staff having a huge impact on their day to day work.

Why mental health promotion?

By promoting mental health, prison staff and prison healthcare staff can use an evidence-based approach which will build emotional resilience and diminish mental illness. This approach will let you actively promote a prisoners mental health so that the problem has less chance of coming back and prisoners are better equipped to deal with life on release.

W O R K S H E E T 1

What is the `big idea' in using these worksheets?

By systematically applying some simple techniques you will discover a rewarding way to tackle these common difficulties. At the heart of this approach is the creation by you of a practical mental health promotion resource.

The practical task is to build a list of your local mental health promotion resources which staff can use in their daily work.

This mental health promotion consultation prompt card will provide an invaluable local and practical resource which can help you see prisoners' problems in a different framework, one which is built around their mental health.

How do these worksheets work?

You do NOT need to be a mental health expert to develop this resource. These worksheets will let you do this with minimum work, effort and expenditure of time.

A couple of short meetings for a group with someone spending a few hours gathering information between sessions.

It's easy!

By working systematically through these worksheets your group can create its own local mental health promotion consultation prompt card. By using this card, you will grow more confident to deal with mental health issues for prisoners.

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Facts on mental health promotion and offending

Breaking the vicious circle:

Mental health is a big problem and plays a major role in offending Many have mental health problems before they enter prison and often these will be compounded by the sentence On release, any mental health problems may compromise critical elements in a successful resettlement, such as attempts to re-enter work and secure accommodation This in turn may worsen the mental health problem And this in turn may cause further re offending

Relationship difficulties, poor housing, few skills, low income

W O R K S H E E T 2

Offending behaviour / re-offending Anxiety, depression, substance misuse

To illustrate this, one prisoner's story;

" Something' serious happened 18 years ago when Laura was just a teenager (rape). In prison, Laura got access to a counsellor for the first time. In one session, it closed the door on `it'. It was the reason why she was there (in prison). All part of her offending. Doors opened for her after the session. She became (even) more positive. Got a job. Inspired others (prisoners) all round to be more positive. Got out".

Offending, re-offending and mental health: Some of the facts

Prisoners and mental health overview 9 out of 10 prisoners will suffer from a mental illness during their lifetime (that is before a prison sentence, during a sentence, and/or on resettlement Mental health issues are a major factor in crime, offending behaviour, resettlement and re-offending Of crime 70 % is drug related 40% is alcohol related 55% is linked to thinking and behavioural problems 57% of ex offenders are re-convicted of a further offence within 2 years

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Before entering prison 20% males and 37% females have attempted suicide in their lives prior to conviction / prison 60 ­ 70 % of offenders are using drugs 20% of male and 15% of female sentenced prisoners have previously been admitted to a mental hospital Once in prison 90% have a mental health or substance abuse problem 72% of male and 70% of female sentenced prisoners suffer from two or more mental health disorders; 14 and 35 times the level in the general population respectively. 7% of male and 14% of female sentenced prisoners suffer from severe and enduring mental health problems (psychotic disorders); 14 and 23 times the level in the general population respectively.

W O R K S H E E T 2

On release from prison 50% of ex offenders have no GP Drug related death is seven times higher in the 2 weeks after release Suicide risk is highest in the first 2 weeks post release

Breaking the re offending cycle

Finance and mental health: In one project 50% of prisoners who received finance and debt management help during and after their sentence retained their tenancy on release BUT people with mental health problems are three times as likely to be in debt than the rest of the population On top of this, 33% of offenders debt problems worsen in custody Employment and mental health: Being in employment reduces the risk of re-offending by up to 50%. BUT people with mental health problems have more than two times the risk of losing their job AND 66% men under 35yrs with mental health problems who die by suicide are unemployed On top of this, before a prisoner starts their sentence 60% are unemployed. Of the 33% who do have a job, 66% prisoners lose their jobs while in prison Accommodation and mental health: Having stable accommodation reduces the risk of re offending by 20% BUT 25% tenants with mental health problems have serious rent arrears & at risk of losing home On top of this, on release 42% of ex-offenders have no fixed abode. 33% lose their house while in prison

To illustrate these points, one prisoner's story;

"You don't work and have debts to pay back on the outside. You can't be bothered. It's not just what happens now in prison. You can't be bothered about the future. With release date coming you get more panicky. Got to get out. Got to get a job. You can't pay the money back. You have no way to earn it. You get your release, but then you have to pay back your debt, even make yourself bankrupt. You can't afford to keep up a house. You have no job. You keep on the dole. Live in council accommodation. Live on benefits."

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Education and mental health: In one project prisoners who took an educational qualification 70% found employment on release BUT young people with mental health problems, may miss out on education to gain them useful skills & experience for work On top of this, most offenders have suffered school exclusion. 50% have reading skills less than a 11 year old Physical health and mental health 83% of elderly prisoners have one or more chronic physical health problem 80% smoke 60% of people with a chronic physical health condition are depressed. Depression has a significant impact on health outcomes for chronic physical illness including asthma, arthritis and diabetes [14]

W O R K S H E E T 2

To illustrate this, one prisoner's story;

"A prisoner with high blood pressure, over weight and with a history of strokes. She needs to reduce her weight and decrease her blood pressure. She's stressed out. Legal things keep coming over her; holding a lot of stuff in; pulling her hair out in handfuls. Comes to the gym. She gains a sense of achievement. She can see physically on the graph her blood pressure dropping. She's done that. She can see it. She's much more positive." (Health Trainer, Peer Educator)

Drug and alcohol difficulties Female offenders are more likely than the general population to misuse and be addicted to alcohol or other drugs. · 41% of sentenced women are being held for drug offences. · Approximately two thirds of women prisoners have a drug problem. · Domestic violence or other family conflicts can be a particular factor that contributes to substance misuse. · Women are more likely than men to be multiple drug users.

To illustrate this, two prisoner's stories

Path A: "You come to jail using drugs. Get cleaned up. Get out. Get kids back. Get a job. Path B: "You come to prison. You get a habit. There's peer pressure. You get bored. Your social habit gets into a proper habit. Sweats, shaking, sweating. Can't sleep. You argue with everyone. Can't settle to anything. You "exit". You go through rehab. The habit keeps you in (prison) longer. If you can do rehab and then go the gym for sessions it helps. It's the feel good factor of exercise. You are more positive, Look so much better. Not off your head all the time. You don't need it (drugs). Replace "it" with something you can actually see as you improve. You can physically look at your self. Face full. Not a skeleton any more. Women go on to wear new clothes. Look good. Feel good. Make changes

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Contact with family Over 2/3 prisoners lose contact with their families BUT loss of family is a significant factor in depression. AND Women prisoners are more likely to state that financial hardship, particularly in relation to their children, contributed to their crime On top of this, women's prisons are frequently located long distances away from inmates' homes (average 62 miles), making visiting difficult and increasing the sense of social isolation. To illustrate this, one prisoner's story;

W O R K S H E E T 2

"You miss your children. You haven't seen them. You worry about who is looking after them. You hear things coming back about problems. You go for childcare resettlement leave. You get it and life is great. You don't and you go on a downer. Refuse to go to work. Stop eating. Start cutting up. What you need is to call a listener. What you need is to know how to work out how to work out the problem and make an appeal."

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The Role of Mental Health Promotion in the Support of Prisoners

What is mental health promotion? Mental health is about emotional well being and resilience. When we are mentally healthy we can make the most of opportunities; learn how to make the best decisions; survive pain, disappointment and sadness; fully engage and participate with others within our families and communities.

W O R K S H E E T 3

By promoting offenders and ex offenders mental health, you are supporting that person to maximise their opportunities for: improving their health (mental and physical); achieving better quality of life; making a positive contribution; exercising mentally healthy choice; increasing economic well being. You are also reducing their risk of re offending. Mental health promotion works by increasing mental health promoting factors (protective factors) such as positive relationships, stable housing arrangements, meaningful employment; and decreasing those factors which damage or reduce good mental health (risk factors) such as boredom, abuse or violence. Activities which promote mental health may also prevent mental and physical illness. Mental Health promotion is applicable to all. Fig 1 Factors influencing mental well being

delivering mental health promotion, Fig 3.8 P 49,Dept. Health 2002

Taken from:

Making It Happen ­ A guide to

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Who can offer mental health promotion? You can! You may feel that supporting an offender and ex offender with their housing and education is not much different to what you do anyway. However, the difference here is that by acknowledging that mental health is important, it will help you reframe these difficulties and provide new effective ways of tackling them. It will also reinforce the importance of what you are doing normally to provide holistic support as a way to enhance mental well-being. Along the prisoner's journey in prison and on resettlement, mental health promotion can be provided by:

W O R K S H E E T 3

Prison sentence Release I-------------------------------------------------------------------------------------------I -----------I Prisoner contact with: Health Trainers Prison Officers GP / Listeners Prison Health Staff Chaplain CPN Probation Offender manager

Mental health promotion is not a specialist activity. A lot if it is common sense. You can feel safe and happy offering mental health promotion guidance to all. However, you do need to feel happy that you can either make a mental health assessment or ask a GP or specialist mental health professional to do one if need be. When should mental health promotion be offered? Mental health promotion should start as soon as a prisoner enters the prison for their sentence. It should continue on resettlement, provided by GPs, probation officers and primary care mental health workers (such as Community Psychiatric Nurses). The main challenge is to create a culture where mental health promotion becomes `the norm' amongst prison staff and those involved in health care. Nor is this just about dealing with people presenting with difficulties to health staff. Especially important to consider is that group of offenders who do not have regular contact with staff. These "hidden" people can need and deserve help as much as any other group. How does mental health care differ from mental health promotion? Mental health care is the set of interventions offered to treat a person with a developed and diagnosed mental health condition. For example this might include moderate to severe depression managed by prescribing and 6 months of psychological interventions.

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A map of the care pathway: NICE (National Institute for Clinical Evidence) in reviewing the evidence of what works best have recommended a stepped care model for the delivery of care to those with depression. This lets us construct a map of how mental health promotion and mental health care compliment each other. Mental Health promotion fits into step 1 and step 2. Mental health care fits within steps 3-5, the treatment interventions being tailored to the severity of the depression. It is important to realise there is overlap and indeed even for those with severe depression a mental health promotion approach is still an important way to support people.

A Map of the Care Pathway for Depression in Adults aged 18 and over

W O R K S H E E T 3

Step 5

Inpatient care, crisis teams

Risk to life, severe selfneglect

Medication, combined treatments, ECT Medication, psychological interventions, combined treatments Medication, psychological interventions, combined treatements Watchful Waiting, Guided self-help, Computerised CBT, Exercise, Brief Psychological Interventions Assessment

Step 4

Joint working between Primary and Secondary Care

Mental Health specialists, including crisis teams

Treatment-resistant, recurrent, atypical and psychotic depression, those at significant risk

Step 3

Primary Care Team, Primary Care Mental Health Worker

Moderate or severe depression

Step 2

Primary Care Team, Primary Care Mental Health Worker

Mild Depression

Step 1

GP, Practice Nurse

Recognition

How do I decide where someone fits on this care pathway? Ask yourself how this map can apply to the support and care of prisoners with mental health difficulties? You may find it useful to put some specific questions to a prisoner to check out whether they may have a depression: 1. During the last month, have you often been bothered by feeling down, depressed or hopeless? 2. During the last month, have you often been bothered by having little interest or pleasure in doing things?

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These questions have been recommended by NICE to help primary care practitioners screen for depression in patients considered to be at risk of developing depression. They do not guarantee a diagnosis of depression but if positive or if there are other clear-cut mental health symptoms then the prisoner will need to be assessed about the severity of their mental health problem and where it might fit in the above map. Assessment tools can be found on the National Institute for Mental Health's website http://kc.csip.org.uk/viewdocument.php?action=viewdox&pid=0&doc=35064&grp=1 What I should do for someone with a mental health problem: People with mild to moderate mental health problems should have the opportunity to use mental health promotion before entering into more complex management. People with more severe mental health problems should have mental health promotion as well as more complex mental health care (step 3, 4 and 5) People with more complex mental health problems and illness such as personality disorder, psychosis, substance misuse, as well as people with physical health problems (60% of whom have a coexistent mental health problem) should also be offered mental health promotion alongside other treatment options. People who are self harming, suicidal or in crisis will need a mental health assessment performing rapidly.

W O R K S H E E T 3

Resources for the treatment of depression: For more information on the Stepped Care Approach go to NIMHE resource on the organisation of care for those with depression http://kc.csip.org.uk/

viewdocument.php?action=viewdox&pid=0&doc=35064&grp=1

Assessment tools can be found on the National Institute for Mental Health's website

http://kc.csip.org.uk/viewdocument.php?action=viewdox&pid=0&doc=35064&grp=1

South Staffordshire & Shropshire Mental Health Trust have developed a useful electronic version of the Stepped Care Model which lets you navigate the treatment options:

http://www.southstaffshealthcare.nhs.uk/goodPractice/DCP/DCP-49163/index.htm

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How To Use The Worksheets

Use the tools within the steps as below. A facilitator with mental health expertise to direct the meetings. Anyone used to leading meetings should be able to manage the steps. You will need to identify a person to lead the overall process making sure it happens. The end product is your own mental health promotion consultation prompt card Stage One ­ getting going - should take up 2 x 1¼ hr staff meeting with 3 weeks in between and some hours of staff time to collect the information. Stage Two ­ staff using the mental health promotion consultation prompt card should produce results and feedback within 6 weeks. Stage One ­ Getting going

STEP ONE Identify person to lead the process

W O R K S H E E T 4

STEP TWO Arrange 2x1¼ hour meeting with 3 weeks apart for interested managerial and clinical staff

STEP THREE In the first 1¼ hour meeting, together complete steps 4,5,6,7

STEP FOUR Together, read the prisoners mental health stories together with the mental health promotion facts sheet and discuss briefly (10 min)

· · ·

STEP FIVE Together, complete the mental health promotion grid (10 mins) Prioritise ONE area from mental health promotion grid (10 mins) Work out 3 simple and small solutions, who can deliver them and the timescale for their delivery (15 mins)

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· ·

STEP SIX Together, read the sample mental health promotion consultation prompt card with its resources such as telephone / web contacts.(5 mins) Work out how and who is to complete the mental health promotion consultation prompt card in the next 3 weeks (10 mins)

STEP SEVEN Make action plan for the second meeting next 3 weeks ( 10 mins)

STEP EIGHT In second meeting in 3 weeks time, review progress

W O R K S H E E T 4

For example: A group of prison staff got together to think about the mental health of their prisoners and how much mental health promotion they were doing. From filling in the mental health promotion grid they saw that they were doing quite a lot anyway but unrecognised as such and in a non-systematic way. The staff group first identified their need to know they weren't missing anyone with depression in need of drug treatment, as well as having a comprehensive list of the telephone numbers of local mental health promotion resources they could use. The health staff agreed to run a training session on depression for all staff and what to look out for. This proactive service compiled a list of mental health promotion telephone numbers and web references.

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Stage Two - Individual staff work

STEP ONE Give to interested staff · the completed mental health promotion consultation prompt card (eg local telephone/ web contacts) · prisoners mental health stories · mental health fact sheet

W O R K S H E E T 4

STEP TWO Ask staff to 1. Read the sheets 2. Keep the mental health promotion consultation prompt card on the desk and refer to in contacts with prisoners in the next week. 3. Note which resources used and if helpful. Note any gaps

STEP THREE Set up a meeting in one week's time with individual staff members to get feedback on the mental health promotion consultation prompt card: · What impact has it had? · What resource gaps has this highlighted? · What other help is needed?

STEP FOUR Take findings back to large working group to find solutions to any issues identified

STEP FIVE Update and complete a final version of the mental health promotion consultation prompt card

Staff members may also want in their pack · · Depression rating severity tool ­ web reference Self help leaflet for depression and anxiety ­ web reference

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For example:

One prisoner was talking to a member of staff about worries of being released soon and how she couldn't get her head around all the practical things she had to do. She had no house to go to and yearned to be reunited with her children. She described herself on "a short fuse", experiencing poor sleep and feeling generally anxious. In particular she was frightened she might "lose it" with the staff and jeopardise her release. Previously the staff member would have offered help but without a mental health framework to think about this prisoners difficulties. However this time she went through the mental health promotion telephone list with the prisoner knowing that whatever was identified as helpful was evidence based and would improve the prisoner's emotional well-being and resilience. The staff member identified self help and problem solving as useful approaches. Having been recently given a set of self help problem solving leaflets she was confident to give out one of these and talk it through. The prisoner came back to see her a week later. She had taken one first small step: working out that the area she wanted to live was where she would get support from her family and yet be at a distance from some of her former acquaintances. What made a difference was being helped to recognise a return to her former acquaintances was causing her to feel anxious. So she also began to plan what needed to happen next. Her sleep improved, her anxiety diminished and her temper calmed. She could see light at the end of the tunnel and began to feel hopeful about her future.

W O R K S H E E T 4

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Prisoner's Mental Health Stories

Use the prisoner's stories with other tools in the pack as a way to see if resources you are suggesting would help the case in question. These stories are conglomerate stories and not attributable to any one person. They reflect the reality for some prisoners and not for others. They have come from prisoners telling stories of prison life, as third parties. They are not the stories of the prisoners who have conveyed them. They are written verbatim. The mental health comments included are not based on assessment, but are included to highlight the possibilities of underlying mental health conditions Child issues "You miss your children. You haven't seen them. You worry about who is looking after them. You hear things coming back about problems. You go for childcare resettlement leave. You get it and life is great. You don't and you go on a downer. Refuse to go to work. Stop eating. Start cutting up.

Possible symptoms of depression, deliberate self harm, eating problems

W O R K S H E E T 5

What you need is to call a listener. What you need is to know how to work out how to work out the problem and make an appeal." Domestic violence "Something happened 18 years ago (rape). In prison, she got access to a counselor for the first time. In one session, it closed the door on `it'. It was the reason why she was there (in prison). All part of her offending. Doors opened for her after the session. She became (even) more positive. Got a job. Inspired others (prisoners) all round to be more positive. Got out".

Breaking the cycle: the importance of positive stories

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"Domestic violence is more an issue for prisoners as women need a safe house when they get out but on a long term basis as they will have problems working and getting housing. In prison women knows the children are safe- in care. They are safe- in prison. They come out and aren't safe and have no where to go. They may do certain things to come back to prison. To keep themselves safe" Substance abuse "You come to jail using drugs. Get cleaned up. Get out. Get kids back. Get job."

Two very different paths

W O R K S H E E T 5

"You come to prison. You get a habit. There's peer pressure. You get bored. Your social habit gets into a proper habit. You "exit".

Low self-esteem. Low mood. Self-medication

"Sweats, shaking, sweating. You go through rehab. The habit keeps you in (prison) longer. If you can do rehab and then go the gym for sessions it helps. It's the feel good factor of exercise. You are more positive, Look so much better. Not off your head all the time. You don't need it (drugs). Replace `it' with something you can actually see as you improve. You can physically look at your self. Face full. Not a skeleton any more. Women go on to wear new clothes. Look good. Feel good. Make changes." Finance "You don't think about your confiscation order until it comes up. Its makes a difference between an October and January release date. Before you have worked out how to do your sentence. 12 months or 12 years it makes little difference. You work it out, have goals and know when the release date is and when you will get home leave. The confiscation order takes this all away cos you don't know how long you will be in and how long your sentence will be increased if you can't pay the money back."

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"You can't be bothered. It's not just what happens now in prison . You can't be bothered about the future. With release date coming you get more panicky. Got to get out. Got to get a job You can't pay the money back. You have no way to earn it."

Possible depression symptoms

Possible anxiety symptoms

W O R K S H E E T 5

"Eventually you will get release, but then you have to pay back your debt, make yourself bankrupt. Your house has been sold. You have no job. You keep on the dole. Live in council accommodation. Live on benefits." Physical and mental health "A prisoner with high blood pressure, overweight with a history of strokes. Needs to reduce her weight and decrease her blood pressure."

So why can't she?

"She's stressed out. Legal things coming over her. Keeping a lot of stuff in . Pulling her hair out in handfuls." "Comes to the gym. She gains a sense of achievement. She can see physically on the graph her blood pressure dropping. She's done that. She can see it. She's much more positive."

Make the link between stress, depression and chronic health conditions

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Exercise "A prisoner who is underweight and wanting to be more muscular. It builds her self esteem to have a fit body. Others all think she is confrontational and she comes over as ignorant. She does prefer her own company but once you get to know her she has a lot of her mind. She's happiest in the gym, comfortable. That's when she is herself. She's ok"

Breaking the cycle: mental health promotion in action

W O R K S H E E T 5

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1

The Health Promotion Grid

Key Domains

General examples of day to day activities The examples are there to help suggest the sort of activities to be included. How much are you or How important is this Your own personal your team doing in area of activity to examples of day to day this domain? you or the team? activities 1 = hardly any 2 = occasional 3 = a fair amount __ 4 = lots 1 = not at all 2 = a little 3 = fairly 4 = very important You may like to jot down examples of activities you are undertaking in this category This might be drawn from individual practice, learning undertaken by practice members, identifiable practice systems or processes or by example

W O R K S H E E T 6

Strengthening Individuals ­ part of your everyday practice

Please think as widely as you can about possible activities that can be seen as mental health promoting_.

Look at the examples of good practice that follow this part of the self assessment tool for more details of most of these bullet points. 1. Enhancing confidence & Self esteem Including: Joint decision making To what extent do you feel you work to enhance the Strength focused consultation self-esteem and self-confidence of prisoners? Paying attention to achievements 2. Talking things over Including: Group work To what extent are you either by signposting or Self help books based on cognitive networking, creating opportunities for prisoners to behavioural therapy talk things over? Listeners Health Trainers 3. Physical activity Including: To what extent are you involved in encouraging Access to Gym physical activity amongst prisoners? Exercise programmes 4. Learning Opportunities To what extent are you involved in encouraging prisoners to access learning opportunities? 5. Support with child issues Including: To what extent do you help prisoners think about Awareness raising and access support networks or other forms of help Self help materials with the child issues? Including: Self help materials Access to learning advisers Health Education

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2

6. Opportunities for creativity To what extent do you help prisoners think about and access opportunities for creativity? 7. Opportunities to gain employment and income Including: Arts Writing as therapy Access to literature Including: Motivational interviewing Vocational guidance

W O R K S H E E T 6

To what extent do you help prisoners think about and gain employment? 8. Support with domestic violence

Including: Awareness raising To what extent do you attempt to offer support and Specific consultation skills interventions for domestic violence? Guidelines about asking about possibilities of domestic violence

9. Addressing mental health of people with chronic physical problems To what extent do you attempt to address the psychological and mental health components of physical, particularly chronic illness? 10. Access to psychological interventions To what extent do you offer opportunities for prisoners to access psychological interventions (mental health promotion and prevention of secondary or more chronic problems?)

Including: Pain management Screening tools Family meetings after chronic illness diagnosis Access to expert patient groups Including: Counseling & psychological therapies Brief interventions

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Consultation Prompt Card: Mental Health Prompting Interventions

Enhancing confidence and selfesteem Talking things over self-help

W O R K S H E E T 7

Encouraging physical activity

Northumberland Self Help Leaflets http:// www.nnt.nhs.uk/mh/content.asp? PageName=selfhelp#

Encouraging access to learning opportunities Support with child issues Opportunities for creativity Opportunities to gain employment and income Support with domestic violence

Addressing mental health and chronic physical health problems Access to psychological interventions

Acknowledgment to David Williams, Walsall PCT and Janice Tait, Sunderland PCT

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