Treatment Barriers and Support for Male Ex-Armed Forces Personnel in Prison

Part 1: Focus Group With Professionals

Professional participants were recruited to the study using a combination of purposive and snowballing techniques to ensure a varied range of roles and perspectives were included. The preferred number of participants in a focus group discussion is between four and eight people (Kitzinger, 2013). To ensure the successful recruitment of an adequate number of participants for the discussion, 10 professionals were invited to take part in the study. Although eight expressed interest in taking part, three were unable to attend on the day resulting in a professional sample size of five people for the focus group discussion (three women and two men, aged 29–62 years).

All professional participants had knowledge and experience of providing support and/or treatment to ex-armed forces personnel, either in the community or within secure settings. Participants’ time in their current roles ranged between 1 month and 20 years. The following roles were included in the group: a prison governor, a Veterans in Custody Support Officer (VICSO), ¹ an armed forces volunteer mentor, a representative from a specialist National Health Service (NHS) veterans service, and a community charity worker. Three of the professionals had experience of service in the armed forces themselves. The decision to conduct a focus group with professional participants, as opposed to individual interviews, was twofold: it enabled the efficient capture of range of perspectives, and the resultant discussion and interaction between participants challenged their different individual perceptions and professional standpoints, encouraging points of consensus to emerge.

Participants were sent an information sheet about the study prior to the focus group discussion along with six short case studies. The anonymous case studies were developed from the larger mixed methods cohort to illustrate the potential variety of issues faced by ex-armed forces personnel in prison and were used to help set the context of the discussion. Each case study gave some basic background on the person—their current age, the age they joined the armed forces, and a brief description of their service. This included factors such as length of service, any experience of deployments, and how they left the armed forces. Whether the person held any previous offences as well as their index offence was noted. A summary of any mental health or substance misuse symptomology was provided along with any self-reported treatment and support needs. Care was taken to ensure no individual could be identified from the information provided and through the use of pseudonyms. Copies of the information sheet and case studies were provided to all participants again on arrival at the meeting.

The focus group took place in a private room at the University of Manchester and was facilitated by V.W. Written, informed consent was gained from all participants before the discussion began, and any questions participants had were answered. Permission to audio record the interview and use anonymized, non-identifiable quotes in the reporting of the data was also given by all participants. As an icebreaker, participants took it in turns to introduce themselves to the rest of the group. To open the discussion, participants were then asked by the facilitator whether they had, or were aware of, any general perceptions of ex-armed forces personnel as prisoners. For the discussion and interaction between participants to develop spontaneously, a topic guide listing the broad areas of interest in relation to the research aims and potential prompts was used rather than attempting to adhere rigidly to a specific set of questions. The areas listed for discussion were professionals’ perceptions of the needs of ex-armed forces personnel in prison, barriers to accessing support and treatment, what a treatment pathway should incorporate, and how treatment and support should be delivered. The focus group came to a natural end after 1 hour and 12 minutes, and participants were debriefed and thanked for their time.

Part 2: Interviews With Service Users

Semi-structured interviews were conducted with service users in five adult male prisons in England between May 2015 and July 2015. Female ex-armed forces personnel were not sampled in the study as they comprise a significantly smaller group and will likely have different support and treatment needs. One-to-one semi-structured interviews were deemed the most appropriate method of data collection with service users for several reasons. There are practical difficulties organizing a group discussion in a prison environment. It was also felt service users would feel more comfortable, and therefore be more likely to engage, when free of any concern that others could potentially breach confidentiality, or use any sensitive information against them, adding to further stigma.

A purposive sampling technique was used to include a range of ages, ranks, length of services, and offence types. All service users who were invited to take part had previously been involved in another phase of the larger study and had consented to be contacted again, including those with, and without, mental health or substance misuse problems and those who had, and had not, sought treatment. An interview guide containing areas for discussion and prompt questions was developed covering what participants considered to be the support and treatment needs of ex-armed forces personnel in prison, whether they had previously accessed any support in prison or the community and their experience of this, and what would encourage or hinder them from seeking support and treatment while in prison. All participants gave informed written consent to be interviewed. Permission to audio record the interviews and use non-identifiable, anonymized quotes when reporting the data was also given by all service user participants. Given the potentially sensitive nature of the interview topics, time was taken prior to the interview to reassure participants that they did not have to discuss anything they did not want to and could withdraw at any time. All interviews were conducted by V.W., a researcher they had met during their previous participation in the study, and to ensure confidentiality, all meetings were held in a private room within the prison establishments. All participants had the opportunity to ask questions and have these satisfactorily answered before the interview began. The interviewer was vigilant throughout the interviews for any signs of distress but there was no indication of this occurring.

Interviews continued until no new information was being captured. In total, 10 male ex-armed forces personnel (aged 25–59 years) were interviewed. The majority had previously served in the Army (90%), and lengths of their service ranged between 4 and 19 years. Most had experienced at least one major deployment during their service (90%), and the most common rank of the sample was Private (60%). Methods of discharge from the armed forces were via disciplinary discharge (50%), end of service contract (30%), service no longer required (10%), and medical discharge (10%). The most common offence types were violence against the person (50%) and sexual offences (20%), and the majority were sentenced prisoners (90%). On average, the interviews lasted for 16 minutes, and ranged between 8 and 26 minutes. Participants were thanked for their participation and debriefed at the end of the interview. All service user participants were advised to speak to a member of staff should they become distressed post interview. Without providing any specific detail about the study or service users’ participation, wing staff were informed of the interview so that they could be extra vigilant for any signs of distress.

Data Analysis

All data were transcribed verbatim by V.W. Thematic analysis and constant comparison was the method of data analysis chosen, based within the grounded theory approach (Glaser & Strauss, 1967). To become as familiar as possible with the data, all transcripts were read and re-read a number of times. During this process, any thoughts, observations, or relevant field notes were noted on the transcripts. In the case of the focus group transcript, any notes on group interaction were also made at this stage. This enabled consensus and disagreement to inform the analysis process, as well highlighting areas professionals considered particularly important. Codes were used to label and describe the data. These codes informed the initial analysis framework which was used to reduce the data and group the codes into categories. Data from the transcripts pertaining to these categories were then separated from the transcripts and grouped together. The “one sheet of paper” method (Ziebland & McPherson, 2006) was used to summarize the data belonging to each code. This enabled identification of broader themes, or the “story,” to be identified within the data. This approach also ensured that all incidents of a code, and any variance in perspective, were included in the analysis process. The focus group data and interview data were analyzed alongside each other so that categories and relationships (including any differences between groups) could be compared and any subthemes identified.

All transcripts were also read by S.M. Regular discussions throughout the analysis process enabled developing themes to be validated. Identified themes were discussed and agreed with all coauthors. The themes reported here are those that explain the perceived support and treatment needs of, and barriers to treatment for, ex-armed forces personnel in prison from a professional and service user perspective.

The Need for, and Variable Support Available in, Prison: “It Shouldn’t Be a Case of Luck to Get the Help You Need”

There was discussion about the variability in support across the prison estate in the focus group. One professional participant noted that the commissioning for services in prison was very confusing, with a number of different bodies responsible for different, but interconnected, aspects of service provision. She went on to say that service provision across the prison estate needed standardization. This prompted support from another participant who declared, “It’s a big postcode lottery in terms of provision and it shouldn’t be.” The discussion then lightened with the group talking about how the chain of command in the armed forces means personnel always know who they need to go to. This line of discussion seemed to emphasize that ex-armed forces personnel would benefit from clearer support pathways, and signposting, in prison.

During the individual interviews, it was clear that many of the men viewed prison as an opportunity to access the help and support they needed, whether that be for drug or alcohol problems, mental health issues, or community resettlement. The need for this support was often emphasized by explaining it was to ensure they did not come back to prison after release. For instance, “Support for just getting off the drugs and that and help for getting employment when I get out because look where it’s landed me—I need to make sure that doesn’t happen again.” One man considered the link between mental health and offending behavior on a deeper level, emphasizing the potential for prison to reduce the likelihood of reoffending and recognizing the importance of identifying mental health problems as early as possible.

If they’re offending for mental health reasons . . . making . . . giving them help for that problem will make it less . . . maybe you won’t reoffend . . . I don’t know what there is to stop people offending in the first place but maybe if some of these issues were picked up earlier . . .I don’t know . . .

However, men who had been held at different prisons during their sentence talked about the variability in support offered:

Not straight away no, it wasn’t until I went to my second prison when I’d been sentenced, that’s when I found out—I put in an application and that’s when I spoke to the officer—there wasn’t really much support in the other prison for veterans in custody.

Another, who had recently begun the process of accessing support for his post-traumatic stress disorder (PTSD) via the VICSO at the prison was due to be transferred to another establishment at the time of the interview, and not knowing what support was available was a worry for him: “I don’t know how it works in (prison), whether they have any support at all so . . . I’ll probably just have to start it all again.”

For two men, the help they had received in their respective prisons for their mental health problems had had a tremendous impact, with both expressing that they felt it had saved their lives. For both men, the support had been provided by a single member of staff at each establishment, and they felt that, if it had not been for that person, they would not have received the support they had needed. The following two extracts describe their experiences.

I mean for me, like I say, if you’d taken [name] out of here, I know I keep saying her name but I think realistically she saved my life, but if she wasn’t here I don’t think my mental health issues would’ve been dealt with because they weren’t understood so . . .

Similarly,

The lady that was doing it she was doing that course off her own back, paying for it herself because she was interested and so . . . if she wasn’t there I wouldn’t have had any help . . . there was nothing in place otherwise that way . . . it shouldn’t be a case of luck as to whether you get the help you need for these issues . . .

The inconsistency regarding acceptance of PTSD as a mental health problem and awareness of diagnosis and treatment for combat-related PTSD in health care teams was a particular concern for some members of the focus group. However, overall the group felt that most establishments were equipped to deal with such a diagnosis.

The Difficulty of Asking for Help: “It Can Take a Lot for You to Ask for That Help”

Perhaps unsurprisingly, given the masculine culture of the armed forces, many of the men discussed how they found asking for support difficult. Mental health stigma and fear of being given the “label” of having mental health problems were concerns for many. Often, with reference to a range of “macho” qualities synonymous with the armed forces, a number of the men talked about the difficulty they had reconciling these qualities and their need to seek emotional support: “I don’t like asking for help, I feel like I need to be independent, strong . . . but it all builds up from time to time doesn’t it?” Another man commented,

Yeah I suppose . . . I knew deep down I needed help but I just didn’t . . . I think that’s one of the main issues—admitting it, admitting you need help because being ex-forces you’re used to being self-sufficient . . .

Indeed, the focus group discussion also highlighted difficulties with stigma resulting in agreement within the group that the stigma of mental health issues in the armed forces was a reflection of wider society:

The thing with the army is that there is still a big stigma relating to mental health.

Definitely . . .

But I think as a society as a whole we’re trying to do away with the stigma in mental health but I think it’s just more intensified with ex-services.

For the men, staff, and other prisoners, being aware of their mental health problems was a primary concern. This was often talked about in terms of fear of embarrassment and being perceived as “weak” by others. However, a number of the men related this fear of being labeled to concerns of this making them vulnerable in the prison environment. One man drew comparisons with his time in the armed forces to explain this:

I wanted to keep my head above water . . . get used to it [prison] and not draw any unwanted attention to myself—if someone knows you’ve got a weakness they’re going to work on that and it’s survival of the fittest in prison—the same as when you’re out there fighting . . .

Another man commented, “You don’t want to show any sign of it, especially in prison, showing weakness can be exploited.”

With this fear of vulnerability due to the perceived stigma attached to mental health issues, the men also considered certain processes and procedures within the prison establishments as unhelpful in facilitating disclosing problems and accessing support. Confidentiality was of particular concern: “It killed me because as I said it’s a sign of weakness and there’s none of this confidentiality, it doesn’t happen—screws talk, nurses talk, everybody talks in prison.” Another man explained,

Well you get someone from mental health coming to your door when you put an app in the night before but they come to your door with an officer so . . . you don’t feel . . . it’s not confidential . . . you don’t really want to say “I’ve got mental health problems” when you see that officer about most of the time.

It was also felt that routine reception screening on entry into prison did not provide a supportive environment to disclose problems. As one man eloquently put, “When the officer on the desk looks up at you when you come in and says ‘any mental health problems?’ looking bored, it’s going to be ‘no’ isn’t it?” This man went on to comment that another opportunity, at a later stage, to engage with mental health staff would have been helpful. The men frequently gave examples of previous negative experiences where they had not been provided with appropriate support after seeking help and how these experiences made it harder for them to ask for support. One man explained his experience of seeking support in the community prior to his offence as follows:

I’d gone to my GP and she was concerned that I was suicidal so she referred me to [name of charity] and it was them that advised I drink herbal tea so . . . not good . . . not the best advice . . . it can take a lot for you to ask for that help so then to get that as advice . . .

Another man relayed his experience of seeking support in prison:

I initially asked for help in [prison name] and they said because I’d be moving to another prison . . .you’re not our problem, you’ll leave here and be somebody else’s problem and that was the mental health team who’d come to ask if I had any issues and I said that I was ex-Army and had been through quite a bit and he said “we can’t do anything for you” it was a bit of the sloping shoulder to be honest . . . so . . . didn’t fill me with confidence.

A number of the men worried that mental health staff in the prison would not understand issues particular to ex-armed forces personnel and this would make asking for support more difficult:

I’d feel a little embarrassed you know? . . . I’d feel a little embarrassed to go to someone . . . especially if they couldn’t understand what I was . . . if they couldn’t relate to what you’ve gone through it would be quite difficult to explain to them.

Problems are different to the average guy who’s not going to see war, see his friends die, explosions, being shot at . . . it’s a totally different type of problem from other prisoners and maybe it’s those issues that can have an effect in other ways like depression so . . . it’s complicated.

In addition to the concern participants had regarding staff being able to understand issues specific to ex-armed forces personnel, the latter quote also demonstrates some of the experiences these men may be trying to cope with in custody.

The Importance of Military Awareness Among Staff: “Some Understanding Is Necessary for Someone to Open Up”

The Importance of Preparing for Release: “I’m Afraid of Getting Out of Prison”

Resettlement support was a topic mentioned frequently during the focus group with professionals. The discussion evolved from a conversation about why some ex-armed forces personnel become involved in the criminal justice system to considering their support needs in prison. The majority of the group became involved in the discussion and all agreed that employment, housing, and a support network were essential for a successful transition out of prison. One group member drew comparisons with the transition out of the armed forces and the transition from prison, prompting agreement from the rest of the group. She commented as follows:

It’s about getting them to fit back into society, that’s what we need to be preparing them for in prison . . . they have exactly the same transition issues [as when they leave the armed forces] when they come out of prison—it’s not different and there’s really not a lot of help.

This comment seemed to highlight that the transition difficulties some of the men experienced leaving the armed forces may have contributed to their offending. Therefore, helping them to make the transition out of prison successfully was considered all the more important.

Many of the sentiments made by the focus group were echoed in the service user interviews. Often the information cited as being useful by the men was regarding through-the-gate (i.e., resettlement) support, with a lot of focus on employment opportunities: “I’ve always worked—I’ve never not had a job but having been in this place you’re labeled aren’t you? Going back to the civilian world is daunting . . . it’s daunting for everyone I’ve spoken to.” However, housing, continued support for mental health, and substance misuse concerns were also discussed. All the men considered the transition out of prison to be important, and it was a significant worry for a number of the men. One man with alcohol misuse problems said, “The only thing I’m afraid of is getting out . . . I get more support in here.”

Some of the men felt they would worry less about the transition from prison if they were able to access information and take an active role in their release planning well in advance of their release date. Continuity in the service provision was also considered important:

It would be good if there was allocated time so that these people can come in and give you the information that could help you prepare for getting out, information that is specific about the help that is available and you can be in touch with them before you get out so there’s a continuity which I think would give you a peace of mind.

Another man commented:

I’d prefer to engage with the people to know things will be put in motion—put my mind at rest rather than get to the 6 month point and when you’re getting ready to be released and you have no contacts . . .

Through-the-gate provision was deemed particularly important for three of the men who had come into prison straight from the armed forces. All three had joined as teenagers and consequently had no adult experience of civilian life, making the transition from prison a real worry:

I don’t know where I’d start—it’s all new to me, I’m fucking going out to the big bad world . . . I haven’t got a clue to be honest . . . any resources to help me start a life out there . . . everything because I’m going to be new to being a civvy . . . even putting a leaflet up that you can read or having a dedicated slot to talk to someone about what you need . . . something.

In addition to the practicalities of housing and employment, these men discussed the need for coping skills in civilian life:

I joined the Army at 16, served for 7 years in there and now I’m here [prison] so I think it’s about getting coping mechanisms in place that would stop the worry like . . . how to deal with things in the civilian world.

For another, these were coping skills specifically related to his PTSD diagnosis:

It’s needing a house, a job, linking in with help for the PTSD to keep the wolves away from the door as I’ll always have that, that would be a start but because when I get out I’ll be settling nowhere near here there’s not much they can do anyway . . . it’s just trying to put things in place so that I can have the best chance to get back on track—I still jump when there’s a loud bang after all this time and it sets me back another couple of weeks so I want to make sure I can cope on the outside.

This extract also demonstrates the worry for some of the men about the lack of information regarding provision in areas not local to the prison. This was an issue which came up more than once during the course of the interviews.