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The Mental Health of Men and Boys Inquiry

Written evidence submitted by Dr. Karen Slade, Dr. Sarah Seymour-Smith and Professor Carrie Paechter, Nottingham Trent University.

We are happy to provide oral evidence if required. Please contact Professor Carrie Paechter on carrie.paechter@ntu.ac.uk for further information.

1. Executive Summary

  • Our submission is based on three bodies of research:
  • Research by Dr. Seymour-Smith into online and face-to-face support groups for adult men suffering from physical illnesses
  • Research by Dr. Slade into poor mental health and suicide risk for men coming into contact with the criminal justice system.
  • Research by Professor Paechter into an online support community for people going through separation and divorce.
  • Men find it easier to talk about their emotions if it is presented as helping others. This is also facilitated by support taking place online
  • Women in heterosexual partnerships play an important role in supporting their partners to discuss their emotional vulnerability
  • Men in the criminal justice system are at exceptional risk of suicide and self-harm
  • There are no agreed assessments, pathways or interventions for men in England and Wales at risk of suicide or lethal self-harm in Police or Court custody. This needs to be addressed with a coordinated response similar to the multi-agency response in the prison service
  • Mindfulness and Cognitive Behavioural Therapy can be effective for prisoners with depression and anxiety.

2. Submission

Our submission is based on three bodies of research:

  • Research by Dr. Seymour-Smith into online and face-to-face support groups for adult men suffering from physical illnesses and how these can support better mental health for men in these circumstances.
  • Research by Dr. Slade into poor mental health and suicide risk for men of all ages coming into contact with the criminal justice system.
  • Research by Professor Paechter into an online support community for people going through separation and divorce.

Men suffering from physical ill-health

Dr. Seymour-Smith’s research has identified that gender is a barrier to men’s participation in self-help groups (Seymour-Smith, 2008). She suggests that men can feel that going to a self-help group is a sign of weakness and so may be reluctant to attend. The men she studied had found reasons to attend the groups which did not imply that they needed help themselves and were focused on being proactive, such as giving advice to other men or working to change treatment practices for patients. The men also removed the term ‘self-help group’ from their advertisements in order not to deter men from attending.

Dr. Seymour-Smith’s (2013) research also shows that emotional talk between men is possible if it is presented in a way that is understood as being rational and understandable (e.g. through saying that any man would feel like this). This was easier for men to do in an online community: the research indicates that online settings can allow emotional talk to be treated as normal. Dr. Seymour-Smith’s research suggests that online support is therefore potentially useful to men experiencing emotional difficulties. This finding is supported by Professor Paechter’s (2012) research into online divorce support communities, in which men reported that they found the anonymity of an online site made it easier for them to express their feelings.

Dr. Seymour-Smith (Seymour-Smith and Wetherell, 2006) also found from her research with heterosexual couples that when one of them is ill, women act as emotional caregivers and take over the storyline at times when it is difficult for men. An example of this is that when one man was talking about recovering from prostate cancer surgery he said that he just sat around watching television, at which point his wife said, ‘but you did have a lot of pain’. This allowed the man to acknowledge his vulnerability during his illness. Healthcare providers need to be aware of the ways in which women in heterosexual couples provide this emotional bridging, even when they are themselves ill. Furthermore, in heterosexual couples, it is typically the woman who instigate men’s presentation to health services as they often act as the ‘health supervisor’ in family situations (Seymour-Smith, Wetherell and Phoenix, 2002).

Men and boys in contact with the criminal justice system

Research has repeatedly identified that people in contact with the criminal justice system are at exceptional risk of suicide. This is reflected within the Government’s own national Preventing Suicide in England (updated 2017) strategy.

However, there are no agreed assessments, pathways or interventions for men at risk of suicide or lethal self-harm within England and Wales within Police or Court custody. Indeed, Dr. Slade’s research suggests that Criminal Justice Liaison and Diversion (CJLD) or mental health services do not currently respond to all men in custody considered at risk of suicide. (Slade, Samele, Valmaggia and Forrester, 2015). This study also demonstrated that suicide risk without additional serious mental health concerns may fall outside of the agreed remit of some health services. Additionally, the study found that this group are at high risk of later suicidal behaviours or severe mental health concerns in the early stages of imprisonment. Limited response at an early stage may therefore be escalating risk into the prison setting (Ministry of Justice, 2019). There is an opportunity to intervene with preventing serious self-harm, which requires a broadening of remit and specific service pathways for those at high risk of suicide.

Further research by Dr. Slade and others (Forrester et al, 2016), examined a mental health service pilot scheme in police stations in London. They found that 16.2% of cases (both women and men) reported suicide ideation. In total, 82.6% of the suicide ideation sample also reported a history of self-harm or a suicide attempt. Suicide ideation was also associated with certain diagnostic categories (depression, post-traumatic stress disorder and personality disorder), a history of contact with mental health services, and recent (within 24 hours) consumption of alcohol or drugs. The previous contact with services and previous self-harm or suicide attempts indicates prior intervention opportunities which could reduce risk of harm.

A further study by Dr. Slade and others ( Forrester, et al, 2017), identified the alarming fact that amongst those referred for a mental health assessment in police custody, over a third had a history of suicide attempts, with over a tenth reporting active suicidal ideas, and that almost a fifth were assessed as presenting a suicide risk. This indicates a need for services that are able to identify and manage the resulting risks (including the provision of observations when they are needed). Additionally, almost a tenth of referrals had already harmed themselves. We recommend the need for a coordinated response to self-harm and suicide risk and behaviours within police custody that is similar in its approach to the multi-agency response that was introduced by the prison service to address safety issues in the prison estate.

Dr. Slade’s recent systematic review and meta-analysis of 37 studies of randomly controlled trials of psychological therapies with mental health outcomes in prisoners (Yoon, Slade and Fazel, 2017) concluded that cognitive behavioural therapy (CBT) and mindfulness-based therapies are modestly effective in prisoners for depression and anxiety outcomes, although effects were not sustained on follow-up at 3 and 6 months. No differences were found between group and individual therapy, or different treatment types. Additional psychological treatments need stronger evidence before they could be considered in prisons.

Research by Dr. Slade and others evaluating men accessing secondary mental health services in prisons (Forrester, et al, 2014) suggests that the characteristics of those referred are similar to those of the wider prison population. Although many are already known to services, an important sub-group comes to the attention of mental health services for the first time through the criminal justice system. The criminal justice system therefore has an important role to play in the recognition and treatment of mental disorder.

3. Recommendations

  • Support groups for men experiencing serious illness need to be carefully promoted in line with men’s reservations about being labelled as individuals in need of support. Promoting any relevant contributions they could make might appeal to men.
  • Online emotional support should be provided for men experiencing emotional difficulties, and support given to the formation of online support communities
  • Health professionals should be given training into the role of female partners in supporting men in expressing their emotional vulnerabilities and needs
  • The remit of mental health provision within the criminal justice system should be broadened to encompass Police and Court custody and specific service pathways provided for those at high risk of suicide
  • There should be improved screening arrangements across all criminal justice system pathways, both at reception and in the induction period, to better facilitate the recognition of those with mental health problems
  • Additional services are needed to manage the risk of suicide and self-harm of prisoners in Police and Court custody, including provision for observations where needed
  • A coordinated response to self-harm and suicide risk in Police and Court custody should be developed, similar in its approach to the multi-agency response introduced by the prison service to address safety issues in the prison estate
  • Cognitive Behavioural Therapy and Mindfulness based therapies should be introduced and/or increased to support prisoner mental health
  • Research should be commissioned into the efficacy of other psychological treatments for the mental health of prisoners
  • There should be greater investment in services for foreign national prisoners, including staff training, advertising, cultural inclusion and language assistance
  • Research should be commissioned into a comparison of Mental Health Service models, working towards agreed model templates

4. References:

FORRESTER, A., SAMELE, C., SLADE, K., CRAIG, T. and VALMAGGIA, L., 2017. Demographic and clinical characteristics of 1092 consecutive police custody mental health referrals. The Journal of Forensic Psychiatry & Psychology, 28 (3), pp. 295-312. ISSN 1478-9949.

FORRESTER, A., SAMELE, C., SLADE, K., CRAIG, T. and VALMAGGIA, L., 2016. Suicide ideation amongst people referred for mental health assessment in police custody. Journal of Criminal Psychology, 6 (4), pp. 146-156. ISSN 2009-3829.

FORRESTER, A., SINGH, J., SLADE, K., EXWORTHY, T. and SEN, P., 2014. Mental health in-reach in an urban UK remand prison. International Journal of Prisoner Health, 10 (3), pp. 155-163. ISSN 1744-9200.

Ministry of Justice (2019) Safety in Custody Statistics, England and Wales: Deaths in Prison Custody to December 2018 Assaults and Self-harm to September 2018. Accessed at Safety in Custody Statistics Bulletin, England and Wales, Deaths in prison custody to December 2016, Assaults and Self-Harm to September 2016 (PDF, 294KB).

PAECHTER, C. (2012) Online learning in divorce: how the formation of a community of practice in a divorce support website enables and inhibits learning. E-Learning and Digital Media, 9:4, 392-405.

SEYMOUR-SMITH, S. WETHERELL, M. & PHOENIX, A. (2002). “My wife ordered me to come!”: A discursive analysis of doctors’ and nurses’ accounts of men’s use of general practitioners. The Journal of Health Psychology, 7(3): 253-267. Doi: 1359–1053(200205) 7:3.

SEYMOUR-SMITH, S. & Wetherell, M. (2006) “What he hasn’t told you”: Investigating the micro politics of gendered support in couples co-constructed accounts of illness. Feminism & Psychology, 16(1), 105-127. Doi: 1359–1053(200205) 7:3.

SEYMOUR-SMITH, S. (2008) “Blokes don’t like that sort of thing”: Men’s negotiation of a ‘troubled’ self-help group identity. The Journal of Health Psychology, 13: 798-803. Doi: 10.1177/1359105308093862.

SEYMOUR-SMITH, S. (2013). A reconsideration of the gendered mechanisms of support in online interactions about testicular implants: a discursive approach. Health Psychology, 32(1), 91-99. Doi: 10.1037/A0029507.

SLADE, K., SAMELE, C., VALMAGGIA, L. and FORRESTER, A., 2016. Pathways through the criminal justice system for prisoners with acute and serious mental illness. Journal of Forensic and Legal Medicine, 44, pp. 162-168. ISSN 1752-928X.

YOON, I., SLADE, K. and FAZEL, S., 2017. Outcomes of psychological therapies for prisoners with mental health problems: a systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 85 (8), pp. 783-802. ISSN 1939-2117.