An overview of how the conceptual platform is integrated with the structure of the envisaged intervention is shown in Fig. 2. The three columns delineate different key interactions over time, before and after release, whilst participating in a mental health improvement intervention. Dashed lines bound the interactions during which mechanisms activate. These contextualised interactions can be between practitioners and offenders, between the practitioner/offender and other practitioners, or between the offender and family members, peers, or mentors. At the focal point of the intervention are the core interactions between intervention practitioners and offenders. It is within these interactions that the effect of the intervention on practitioners’ behaviour, thinking, and emotion has the potential to affect offenders’ behaviour, thinking, and emotion. In between these core interactions, the interactions of both the practitioner and offender with other people (the central three circles in the graphic) affect change in their behaviour, thinking, and emotions and how these interact with their contexts. These changes impact on the subsequent interaction between the practitioner and offender and generate other potentially beneficial effects.
Categories within the semi-circles show the headings under which the 75 consolidated explanatory accounts (referred to in parentheses; listed in Additional file 4) are presented below. The narrative below presents the conceptual platform for how an intervention to promote mental health across institutional and community environments theoretically operates.
Practitioners—organisational context
Practitioners work within organisations, and the day-to-day operation of organisations impacts on the extent to which practitioners can deliver services that are person-centred. If there is congruence between the goals and values of practitioners and the organisation in which they work, then the resources provided by the intervention are more likely to be used in the way intended (consolidated explanatory accounts 43, 61). However, as delivery of a person-centred intervention is dependent upon different organisations working together collaboratively, the infrastructure to support practitioners’ work is key. At a strategic level, attaining agreement between organisations about common purpose is a necessary first step (1, 61) but is insufficient without the practical elements that enable these to be achieved day to day. Such elements can include pooled budgets (56) and collaboratively developed formal agreements about information sharing, assessment tools, roles, and responsibilities (1, 52) and the authority to hold practitioners in other organisations to account (52, 58). At an operational level, practitioners need to be given the opportunity to develop their skills (for example, in relation to trauma and self-harm (39, 50)) and have their practice supported by organisational systems that both enable monitoring of individuals in need of care and provide feedback and support that facilitates practitioners’ skill development (39).
Maintaining congruence at both strategic and practitioner levels is vital. An agreement developed between organisations at a strategic level risks piecemeal implementation if it is not congruent with the goals and values of practitioners (61). Organisational agreements do not function solely through their formal status but because they are seen as relevant and workable by practitioners across different organisations. The development of working relationships that can support this inter-organisational congruence may be facilitated by basing practitioners in the same location (53).
Practitioners—social/cultural context
Practitioners rarely consciously decide to work in a non-collaborative way, but non-collaborative practice can arise from the decisions that practitioners make within the organisational and incentive structures, and cultural contexts, in which they work. Collaborative practice can therefore be supported through a range of facilitative organisational measures. If practitioners understand their role, responsibilities, and the contribution that they make within a system of care and around a particular offender, they are more likely to be able and willing to work collaboratively (25). Clear agreements between organisations about these factors, together with the information and communication systems that enable them to be put into practice, are also necessary but not sufficient on their own (2, 25).
Interactions between practitioners and practitioners
Information-sharing and care planning (for the delivery of collaborative care) is not a passive process of diffusion between practitioners working in different locations or care sectors. Even though communication systems and inter-organisational agreements may facilitate information-sharing and care planning (52), they do not eclipse the importance of practitioners’ working relationships both within and beyond their immediate working environment. Collaborative working between practitioners therefore has a relational aspect but also a knowing aspect about the operation of the care system as a whole. These aspects are mutually reinforcing—for example, knowing who to contact and how is insufficient without a practitioner believing that his/her referral will be welcomed (2). A referral that is welcomed provides an opportunity for relationship building (17, 22). Referrals, training, and supervision can support development of a shared language (24) and greater understanding of the care system as a whole and practitioners’ roles within it (22, 32, 37). In summary, an important part of initiating and maintaining collaborative working is fostering both the knowing and relational aspects of collaborative working.
Practitioners—engagement
Interventions and the associated changes in practice do not follow in a straightforward sense from a decision at an organisational level to introduce them. The actions of practitioners are pivotal, as it is through such actions that interventions are made on a day-to-day basis. As practitioners are not passive, their engagement in proposed changes in practice is crucial. This engagement can take place on a number of different levels, ranging from the individual (e.g. facilitating practitioners to feel proud of their work) to the team level (e.g. feeling supported and trusted by colleagues) and through to the organisational level (enabling practitioners to pursue personal and professional goals) (5). The relative importance of addressing each of these levels is unclear, but it may be that it is simply necessary to ensure that all of these levels of engagement are recognised and addressed as judged appropriate in the local context. It is worth bearing in mind that the rationales that practitioners employ in their decision-making are likely to be constrained or enabled by these local contexts, in particular whether or not the work environment is experienced as supportive and colleagues and supervisors are trusted (5).
The extent of concordance between practitioners’ and perceptions at an organisational level of the need (or not) for changes in practice is a key explanatory element of how engagement can take place (6). The extent of this concordance can be first flushed out by acknowledging the potential contribution of practitioners’ experiential knowledge to the development of proposed service changes and incorporating this knowledge as appropriate (8). This enables practitioners to feel that they have contributed substantively to the development of, and have an ongoing part to play in the implementation of, the proposed service changes. Second, as practitioners’ motivations are both intrinsic (such as practising in a way consistent with their personal values and which gives them pride in a ‘job well done’) and extrinsic (such as the approval of colleagues or the financial rewards associated with practising at a higher level of expertise), then practitioners need to believe that there is concordance between achieving these goals and their participation in proposed service changes. Third, as day-to-day work is usually structured in a way that reflects different practitioners’ current roles, status, and degree of autonomy, proposed service changes that challenge these traditional ways of working can demonstrate a significant lack of concordance between practitioners’ and an organisation’s perceptions about roles and responsibilities (7). The extent to which it is perceived that an intervention challenges conventional practice can therefore impact negatively on practitioner engagement.
Practitioners—understanding and skills
Two aspects of practitioners’ understanding and skills were identified as impacting upon their willingness and ability to develop positive relationships with service users. The first relates to knowing about mental health and how mental health problems manifest in people’s behaviour (50). For example, the tension between custody and treatment models can be brought into sharp relief by differences in opinion about how to practice held by health care and criminal justice practitioners (19). The second aspect relates to knowing how to develop supportive relationships with people with mental health problems. This is grounded in knowing about mental health but also requires support to develop practitioners’ ability to practise empathically day to day (36) and to continue to do so through supervision that supports practitioners to learn from reflecting on their own practice (28). The examination of assumptions that underpin practise can inform practitioners’ relationship-building in a way that supports offenders’ transitions into the community. For example, if practitioners assume that offenders’ families can offer the same social and emotional support that their own family could provide, then their potential for supporting offenders to mobilise their own social capital is reduced (41).
Interactions between practitioners and offenders
Engagement is defined by its flexible nature. This can manifest in a number of ways, all of which demonstrate to the individual that their needs and views are taken seriously. For example, recognition of an individual’s unique history and its relevance to their current situation can be demonstrated by accurately reflecting back what has been said (67). Initial engagement may need to strike a balance between recognising past experience (which may be negative) and a potentially positive experience of services in the future (34). Keeping individuals engaged will require ongoing, demonstrably credible actions that achieve access to the range of services that an individual requires to support their mental health both in prison and on release (15, 35).
A genuine recognition of offenders’ individuality is the lodestar that can guide practitioners’ interactions with offenders in a way that promotes engagement and a network of actions and relationships that promote mental health. The core mechanism at play is the motivation that individuals gain from being involved in a supportive working relationship that recognises the humanity, strengths, and particular challenges they face. This mechanism is particularly powerful where offenders experience prison as disempowering and lacking in people that care, as the power difference between offenders and practitioners is reduced (75). The relationship begins at the outset of collaborative care formulation by focusing on how to balance working towards an individual’s goals with evidence-informed treatments (10, 12, 62) and the negotiation of access to services to provide that care (13, 48). Such an approach works towards building on the individual’s strengths, although consideration also needs to be given to the way that an offender’s gender, ethnicity, or religion/spirituality is part of their identity. It is vital to understand how these contextual aspects of identity impacts on an individual’s journey towards improved mental health (64, 65). Offering a choice to the individual as to when meetings take place can facilitate initial engagement, and accurately reflecting back what an individual has discussed can demonstrate understanding and empathy (67). The initial recognition and care formulation is just the first step of the journey towards resettlement, rehabilitation, and mental health on which practitioners can accompany offenders.
The metaphor of accompanying the individual on a journey is useful. The path may be long but has a reachable destination, and travelling along it with others will help to get over the lows and reach the highs. Accompanying a person on this journey requires practitioners to not confine therapeutic interactions to formal therapy sessions (33) and to work flexibly by increasing or decreasing their level of support as appropriate for the individual at different stages (64). The support a practitioner should provide is distinguished by not being judgmental or stigmatising (27, 42) and functions by providing a coherent ‘bridge’ between an individual’s current identity and the future identity they want (27).
The principles of mentalisation-based therapy (MBT) [29] can help structure interactions between practitioners and offenders even when not using MBT as a formal therapeutic approach. An offender’s ability to understand the relationship between their thoughts, emotions, and actions can be enabled by a practitioner’s ability to understand, recognise, and manage the impact of an offender’s mental state (in particular their level of arousal) on their ability to interact. Attaining a non-judgemental understanding of the links between one’s own (and other’s) thoughts, emotions, and actions (‘mentalisation’) involves the practitioner enabling the offender to make use of their own capacities for reflection and future planning (72, 74). Interactions characterised by a willingness to explore issues (rather than simply transfer expert knowledge) and support individuals to attend to their own feelings (rather than identifying and naming these feelings) should support the process of mentalisation (74). Such interactions require a delicate balance to be struck between intellectual analysis and emotional involvement, as both of these capabilities are needed to reflect on the links between thoughts, emotions, and actions and how a person may wish to act differently in the future (72). The creation of a safe and sensitive interpersonal environment is necessary for a person to have the confidence to reflect and ‘mentalise’ whilst regulating his/her emotional state (73).
Remaining responsive to an individual’s circumstances is a key aspect that permeates the supportive relationship. This can manifest in a variety of ways, including maintaining sensitivity to the appropriateness of individual or group work (47); providing care that is sensitive to the unique needs of individuals who have experienced trauma (39); facilitating self-expression across a range of psychological needs through, for example, art therapy (45); and recognising offenders’ efforts to progress (63). When, for whatever reason, the supportive relationship falters, if the practitioner takes the time to address the reasons for this happening, then the risk of discontinuity is reduced (29).
However, the practitioner is not the sole actor in providing the breadth and depth of the supportive relationship described above. Practitioners’ support can provide the foundation and stimulus for the individual to repair or create their own supportive relationships with significant others or peers (30), and/or practitioners can encourage and enable significant others and peers to provide support for the individual that can endure long beyond the end of the practitioner’s supportive relationship (30, 42, 64). In short, the practitioner has a key role to play in cultivating facilitative contexts that allow the supportive community mechanisms of relationships with family and friends to operate.
Offenders—organisational context
For offenders, the prison environment can set the tone for all of the interactions that take place within it and therefore the extent to which offenders are motivated to engage with services. A facilitative environment is characterised by an organisational environment that offers choice in, and access to, services (16). It is also evident in the behaviour of prison staff and the interactions they have with offenders—this can take the form of explaining and consistently applying rules and demonstrating tolerance in interactions with offenders (16). The development of supportive relationships can be assisted when teams of professionals are themselves diverse (for example, in gender and culture), as this increases opportunities for the development of client-practitioner relationships where the client has a particular connection with, or identifies with, a practitioner’s life experiences (57). Although there are clearly restrictions within the prison environment in terms of depriving individuals of their liberty, it can still set a supportive tone for engagement by supporting the common human drive to find meaning in daily activities such as work and exercise (49).
Offenders—perceptions, understanding, and skills
Two key sequential steps in an offender’s progress towards improved mental health are their constructive engagement with services and the cultivation of skills that enable self-care. Engagement requires trust in both individual practitioners and the system in which these practitioners work. Offenders need to have reason to believe that, if they approach and engage with practitioners, they will be treated empathically and fairly (4) and that by discussing mental health issues that may lead to treatment they are not risking a negative impact on the length of their sentence (3). Similarly, offenders need to have reason to believe that communication between agencies is timely and accurate so that care is provided in a co-ordinated manner (4, 32). It is suggested that differences in the perception of organisational boundaries between offenders and practitioners, with offenders seeing ‘one service provided by different people’ and practitioners seeing ‘many separate services with separate provision’, are one reason why offenders’ trust in practitioners and the system can falter (32). If practitioners explore offenders’ concerns (based on their prior experiences), then there is an opportunity to begin engagement even though imperfect service provision is the reality (31).
Engagement provides the foundation for cultivating the skills that will enable self-care. It is suggested that developing ‘mindfulness’ skills, the ability to be aware of one’s own mood state and its relationship with what is currently happening, can underpin the development of other mental health self-care skills (46). In this way, and in conjunction with the development of communication and social skills, an upward self-supporting spiral is initiated—self-awareness can increase receptivity to learning new mental health skills, which increase empathic skills and an offender’s ability to form or re-connect with a supportive social environment, which promotes efforts towards resettlement and rehabilitation (26) and so on. Inspiration by and emulation of others who have had similar experiences can increase ability to self-manage and take personal responsibility (71).
Summary of the conceptual platform
Our findings can be summarised in the form of a conceptual platform, specifying the core set of processes of how an integrated, person-centred system to improve the mental health of offenders with common mental health problems is proposed to work. Such a system works through the following:
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Different systems, in particular health and criminal justice, having goals that are consistent with one another
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Attaining consistency between strategic goals and the goals of practitioners
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Making referral pathways and links between organisations comprehensible to practitioners and providing opportunity for the development of constructive working relationships
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Practitioners being facilitated and enabled to balance factors that can be in tension—for example, ‘knowing how’ as well as ‘knowing that’, analysing one’s own behaviour whilst remaining attentive to emotions, and working towards an individual’s goals
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Practitioners being facilitated and enabled to apply scientific and experiential knowledge judiciously in working with individual offenders, colleagues, and the systems in which services are delivered
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Practitioners having sufficient knowledge about mental health and how to develop supportive relationships with people with mental health issues
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Recognising the individuality of offenders throughout all interactions in the criminal justice, health, and social care systems
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Aligning resources so as to facilitate offenders to achieve their collaboratively agreed goals
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Practitioners supporting reconnection with, and/or development of, networks of support outside of prison
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Offenders having reasons to trust practitioners, services, and systems