Title: Improving health and facilitating desistance in offenders with personality disorder: An intervention development study to maximise participation in prosocial occupation
Funder: Health Education England

Abstract: Background Participation, as defined by the World Health Organisation, is a fundamental component of health (7). Participation refers to performing meaningful activities, i.e. occupations. Prosocial occupations are those activities valued by society, such as work, leisure and self-care. Antisocial occupations are those activities considered deviant, such as crime or substance misuse. Barriers to participation in prosocial occupation contribute to poor health, marginalisation and increased risk of participation in antisocial occupations (15, 17).Approximately two thirds of prisoners have personality disorder(s). Personality disordered offenders (PDOs) experience barriers to participation in prosocial occupation in custody and on release. Participation in prosocial occupation has two important outcomes for PDOs. Firstly, it improves physical and mental health (7), which enhances quality of life among this hard-to-reach group. Compared to offenders without personality disorder, PDOs have higher rates of psychotic, mood, anxiety, substance use and somatoform disorders; more frequent and severe self-harm or suicide attempts; and lower quality of life (8, 18). Secondly, participation in prosocial occupation is associated with desistance, meaning ceasing to offend (12-14). PDOs reoffend at higher rates and are overrepresented in commission of serious crimes (8, 9, 19). Financial implications of poor outcomes amongst PDOs are borne by the public through taxation to fund the NHS, criminal justice and social services. Financial costs can be calculated, but the impact on victim and public health is immeasurable (15, 16). Existing approaches have failed (20, 21), resulting in services for PDOs becoming a priority issue in which NHS England and the National Offender Management Service have invested 24 billion (19, 22). Existing approaches take a psychological perspective of PDOs needs. There remains an absence of literature pertaining to participation in occupation as contributor to health and desistance outcomes, or to interventions designed to achieve participation in prosocial occupation.This study will apply an occupational perspective, i.e. specifically focussing on participation in occupation, to the needs and experiences of PDOs, in order to identify factors that influence participation in occupation, explore how and why they impact on participation, and design interventions to improve participation in prosocial occupation. AimEnable service providers to deliver interventions that facilitate participation in prosocial occupation and contribute to improved health and desistance outcomes for PDOs.Research questionsAmong PDOs: What factors contribute to participation in prosocial occupation? How can service providers intervene to maximise participation in prosocial occupation? Objectives Focusing on PDOs, the study will: Systematically review evidence relating to Factors influencing participation in occupation Effective interventions that target these factors Understand how participation in occupation (prosocial and antisocial) occurs Identify factors that influence participation in prosocial occupation Identify interventions with potential to modify factors that influence participation in prosocial occupation, and improve health and desistance Define feasible interventions that facilitate participation in prosocial occupation Devise an intervention manual for facilitating participation in prosocial occupation Objectives will be met by completing four work packages (WPs), consistent with MRC guidelines for developing and evaluating complex interventions (23). WP1. Two systematic reviews (objective 1). WP2. Qualitative study. Narrative inquiry interviewing PDOs (objectives 2-3) WP3. Delphi study involving expert service providers and academics (objectives 4-5) WP4. Intervention manual development (objective 6) Benefits Absence of research from an occupational perspective, the high priority afforded across services, and the failure of existing approaches indicates this study from a new perspective into the needs of PDOs is timely and beneficial. An evidence-based intervention manual enables service providers to deliver interventions that increase participation in prosocial occupation among PDOs. This will potentially improve health and desistance outcomes and therefore benefit PDOs, victims, and wider society in health and economic terms.

Lay abstract: The things we do every day are called occupations. Our occupations have an important influence on our health and wellbeing (7). Some occupations are prosocial, which means they are thought to be positive by society. This includes things like work, playing sports, and looking after yourself. Some occupations are antisocial which means society thinks they are negative. This includes activities like crime, fighting or taking illegal drugs. People with Personality Disorder find it difficult to take part, or participate, in prosocial occupations. When someone with a Personality Disorder also has a history of committing crimes, it is clear that there are more barriers to overcome. Sometimes this group are called personality disordered offenders' (PDOs). It is important to think about why PDOs find it difficult to participate in prosocial occupations because when people can't do this their health and wellbeing gets worse. We know that PDOs have worse health in many ways and also that they are more likely to get stuck in patterns of participating in antisocial occupations (8-11). Participating in prosocial occupations has two really important outcomes for PDOs. Firstly, it is linked with better physical and mental health (7), which means a better quality of life. Secondly, it is linked with desistance, which means stopping antisocial behaviour like drug use and crime (12-14). Helping PDOs have better health and stop offending will benefit the individual and many other people too. It will benefit the National Health Service (NHS) and other service providers because there will be less people needing help. It will benefit society because there will be less crime and fewer victims of crime. And it will also benefit everybody that pays taxes to help PDOs, victims and society when a crime occurs (15, 16). At the moment, the help for PDOs with the best evidence focuses on psychology. Nobody has looked at the difficulties in participation in occupations before, which means there might be important things missing that could help lots of people. Because there has been no research, people are not offering help that is based on the needs of PDOs and are doing things differently in different places. This means there is no way to test if help looking at prosocial occupation makes a difference. This study will do four things to improve help for PDOs: Find out what research has been done looking at barriers that PDOs have to participating in occupations, and what has been tried to help PDOs overcome these Talk to PDOs to find out what their experiences have been, what is helpful and how services could be better Talk to service providers about what might work best to help with the challenges for PDOs Write a manual so service providers can help in ways that are based on evidence, and is the same no matter where the help is given

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;5.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH