v2.

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10th June 2014
S. Senker & M. Scott
Draft

Literature Review
Offenders with Complex Needs:
Substance Misuse, Mental Health Problems &
Learning Disability

Literature Review

Offenders with Complex Needs:
Substance Misuse, Mental Health Problems & Learning Disability

EXECUTIVE SUMMARY

1. INTRODUCTION
1.1 Methods

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5

2. DEFINITION
2.1 The problem with definition

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6

3. PREVALENCE
3.1 Identifying and estimating prevalence

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7

4. IDENTIFICATION
4.1 The tools of identification

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9

5. RELATIONSHIP WITH OFFENDING

5.1 Substance misuse, learning disability, mental illness and offending

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6. SERVICE USER PERSPECTIVES

13
6.1 The experience & perception of the criminal justice system by offenders with complex needs 13
7. IMPROVEMENTS
7.1 Recommendations for best practice areas for improvement

14
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8. WHAT WORKS
8.1 The existence of modified programmes for offenders with complex needs

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9. CONCLUSIONS & CONSIDERATIONS

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REFERENCES

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EXECUTIVE SUMMARY

INTERLINKED RELATIONSHIPS
There is a strong and recognised relationship between Substance Misuse (SM), Mental
Health problems (MH), Learning Disability (LD) and offending in terms of:
An increased likelihood of committing a range of crimes from acquisitive offences
(drug misuse); violent crime (alcohol and MH), sex offences and arson (LD)and re-
offending (drug users are 3-4 times more likely to commit crime than non-users)
Their prevalence in offending populations (an estimated 25% - 65% of offenders
have MH, 50% SM and 30% LD needs)
Their prevalent, overlapping, co-occurring in nature (dual diagnosis is the norm not
the exception and 60% of individuals with LD will also have an SM problem)

These issues, therefore, have a high cost to the criminal justice system (estimated at 13.9
billion for drug related crime).

Individuals in the criminal justice system present with a variety and multiplicity of needs.
Offenders with these needs are often more vulnerable in the criminal justice system (CJS)
being more likely to experience restraint in custody (LD & MH), violence (alcohol), being
frightened and confused (MH/LD) with higher rates of attempted suicide and self harm (LD).
They are also more vulnerable on exit from the Criminal Justice System, experiencing higher
rates of housing difficulty and unemployment.

Research and campaigning organisations have made strong and enduring calls for dual
diagnosis services (SM/MH) & MH/LD services to be delivered jointly for offenders. These
groups have unequal access to support options available to other offenders, and are then
further disadvantaged.

IDENTIFICATION IS VITAL
Identification of these needs for offenders should be at the earliest possible point in the CJS,
and also repeated on entry to prison and probation.

This is crucial when rehabilitating people to reduce re-offending, not least with regard to
making appropriate referrals and recommendations for their adapting sentences or
facilitating access to suitable treatment.

Due to a number of factors, there is chronic underreporting of these issues for offenders:
There is great variation in the criteria and terminology used to identify these needs
across agencies and across the country
The data not regularly or uniformally captured (e.g. sometimes only a primary
factor can be recorded)
Individuals fear being stigmatised and do not divulge information, meaning that
identification must be sensitively handled
There is a lack of consistent, validated tools with many of those in circulation
requiring specialist skills or training and/or significant time to complete them
Practitioners do not feel skilled or empowered to identify these needs


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GAPS IN CAPACITY & CAPABILITY

The literature identifies a number of key gaps in capacity and capability to identify and
respond to these issues:
Staff skills & awareness training needs have been highlighted around identification,
how to adapt and deliver programmes, and delivery of specific interventions, or to
treat multiple overlapping needs
Service provision some unmet need, divisions between services, no unified services
across these issues, all contributing to a disparate & siloed approach

ADAPTING REHABILITATION
Evidence shows that some adapted programmes, use of appropriate sentencing and
ensuring access to specific support or treatment based on these needs can improve the
efficacy of rehabilitation and preventing re-offending among offenders with complex needs.
Drug treatment can decrease reconviction rates by 47%, and early treatment of mental
health problems is preventative for violent crime.

These findings are in line with the Risk, Need, Responsivity (RNR) Principles used to adapt
rehabilitation programmes by targeting criminogenic needs.

Government guidance and calls from campaigning organisations agree that a Care not
Custody approach may be more effective in rehabilitating offenders with these presenting
issues.

Specific issue treatment programmes have an impact on reducing re-offending. The best
evidence is for drug treatment (2.50 is realised on savings to society in terms of criminal
and health economies for every 1 invested in treatment). However more research is
required to evidence the impact of specialised interventions on recidivism rates for those
experiencing problems with alcohol, MH or LD.

RECOMMENDATIONS TO CONSIDER
The literature points to a number of recommendations that have been regularly made to
help deal with these issues more effectively:

Introduce an integrated service throughout the CJS process and unified across MH,
LD, SM agencies
Terminology and criteria used to identify these needs should be specific and
consistently applied
Tools used to aid identification should be validated, comprehensive and used at the
earliest opportunity and throughout the CJS
Practitioners should feel skilled, confident and competent at identification of these
needs and ensuing adaptation and referral
Agencies and policy makers should consult CJS service users in improving the
response to these needs

1. INTRODUCTION
Individuals in the criminal justice system present with a variety and multiplicity of needs. Identifying
these needs are crucial when rehabilitating people to reduce re-offending, not least with regard to
making appropriate referrals and recommendations for their treatment.
This literature review will attend to the definitions of substance misuse, mental health problems and
learning disability, their prevalence within the criminal justice domain, the tools available and
utilised for their identification, and the way current treatment programmes have been adapted to
cater for these needs. In addition previous recommendations will be considered as well as literature
giving a voice to those in the criminal justice system about their experiences.

1.1 Methods
Attending to the structure of the literature review was an imperative first step to ensure that all
three of the needs (learning disability, mental health problems, substance misuse) were considered
under each subheading. Broad computer based searches of Google Scholar, PSYCHinfo, Science
Direct and MEDLINE were undertaken utilising search terms which co-located offending and complex
needs: offenders with learning disability, offenders with mental illness, offending and
substance misuse. This helped identify some of the dominant journals such as; British Journal of
Learning Disabilities, Journal of Intellectual Disability Research, Journal of Intellectual and
Developmental Disability, Journal of Substance Use and Misuse; Journal of Substance Use
Treatment; Criminal Behaviour and Mental Health, Journal of Forensic Psychology and Psychiatry.
Individual search terms were entered into these journals according to the section being written e.g.
prevalence of offenders with mental health problems; service users perceptions;
modified/adapted treatment for offenders with learning disability. Where papers could not be
accessed, the author was emailed directly (e.g. Professor Rose at the University of Birmingham).
Once a valuable article was found, citing articles were checked as well as the reference section of
each paper. This often led to other useful articles. Government papers were also consulted as well as
statistics from the Office of National Statistics and Ministry of Justice.
Priority was given to UK research in order to give an accurate representation of the current scope of
the problem, this was particularly important for prevalence figures but remained at the forefront of
considerations throughout. Most recent investigations were also privileged, again to provide up to
date, relevant information. It should be noted, that much of the cited research comes from the
prison estate. A lack of academic literature considered probation and custody settings although this
has been investigated recently by a join inspectorate commission for offenders with learning
disabilities. A paucity of research into mentally disordered offenders on probation has been
observed and noted elsewhere (Brooker, Denney, Sirdifield, 2014).
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2. DEFINITION
2.1 The problem with definition
Defining the concepts of substance misuse, learning disability and mental illness has been noted as
an area of difficulty (Bradley, 2009). Therefore it is important to consider the way in which these
three needs have been defined elsewhere, as well as the standard definitions and notations
utilised in research.
Firstly, substance misuse is defined and discussed clinically by the Diagnostic and Statistical Manual
of Mental Disorders (DSM). Such a tool has most recently proposed that an individual can be
classified as having substance use disorder, as well as a specific opioid use disorder1, if they meet
two or more criteria within a 12 month period. These include factors such as a failure to fulfil major
role obligations, continued use despite persistent social or interpersonal problems caused or
worsened by the substance, tolerance and withdrawal effects, persistent unsuccessful efforts to cut
down or control substance use and a great deal of time invested in obtaining, using or recovering
from the substance (American Psychiatric Association, 2012). The latest version of the DSM, DSM-IV,
deliberately combines abuse and dependence following high correlation in factor analysis studies
(Grant et al., 2007). It also paints a picture of substance use disorder being all consuming, affecting
vast domains of an individuals life.
With regards to learning disability, it has been noted that most UK studies utilise a strict criteria such
as an IQ measure of 70 or below in order to diagnose someone as having a learning disability
(Loucks, 2007). However, this can be misleading and should not be used as the only qualifying
criteria as it fails to consider social functioning (Craig, Stringer & Moss, 2006; DoH, 2001). Bradley
(2009) defines a learning disability as having the following three qualities:
(i)

a significantly reduced ability to understand new or complex information,

(ii)

to learn new skills (impaired intelligence),

(iii)

with a reduced ability to cope independently (impaired social functioning) which started
before adulthood, with a lasting effect on development.

In contrast, the term learning difficulty is a more inclusive term and pertains to a wider spectrum of
disorders such as dyslexia and those on the autistic spectrum. The differences in the scope of these
definitions clearly prove problematic when trying to ascertain prevalence, as some studies or
services may not necessarily specify the threshold or definition being used to diagnose someone as
having a learning deficit (e.g. whether they are using disability or difficulty).

Substance/Opioid Use Disorder is defined as a maladaptive pattern of substance use leading to clinically
significant impairment or distress (APA, 2012).

Finally, with regards to the definition of mental illness, Bradley (2009) acknowledges the diversity in
definition from mentally disordered offender (where the mental health problem has a demonstrable
link to the offence) to mental disturbance which does not warrant diagnosis as outlined by the
Mental Health Act (2007) but still causes problems and difficulties for the individual. Terms such as
mental health, mental illness or mental disorder may be used interchangeably and can be
misleading. Mental health can be used to indicate the absence of any mental health problem,
mental illness can refer to presenting symptoms and difficulties, where mental disorder indicates a
clinical diagnosis and meeting of specified criteria. The National Institute for Health and Care
Excellence (NICE) considers depression, generalised anxiety, panic disorder, obsessive compulsive
disorder and post-traumatic stress disorder to be common mental health disorders. Meeting the
criteria featured in the DSM deciphers whether a mental health problem is classified as a disorder.
Prevalence statistics may include any range of dysfunctions or impairments (from identified
problems and difficulties, to clinical diagnoses). The variety in scope makes it difficult to make
comparisons across studies (Forrester et al., 2013). It is important to be mindful of these differing
definitions and criteria in light of the review below, and many research studies offer caveats that
acknowledge the risk of overestimation or underestimation (e.g. Hassiotis et al, 2011).

3. PREVALENCE
3.1 Identifying and estimating prevalence
It has been estimated that approximately 30% of offenders in prison have a learning difficulty
characterised by an IQ of 79 or below, a figure replicated in national and local studies (Bradley, 2009;
Hayes, Shackell, Mottram & Lancaster, 2007). This figure may be even higher in female offending
populations (up to 40%; Mottram & Lancaster, 2006). Although this represents a significant
proportion of individuals across the criminal justice system, the idea that offenders with learning
disabilities and difficulties are a forgotten population has been noted by the Prison Reform Trust in
their No-One Knows programme (Talbot, 2008). Estimates on the proportion of offenders with
mental health difficulties show considerable range. For example, Senior et al. (2013) estimated that
23% 2 of the prison population had a severe mental health problem and acknowledged that prison
in-reach teams do not work with all those identified. For offenders in the community; an
interrogation of probation data at one UK trust yielded a prevalence rate of 27% of offenders with
current mental illness (Brooker et al., 2012). Almost 4,000 offenders were detained under the
Mental Health Act in hospital at the end of 2008. A significant proportion of these were transferred
to hospital from HM Prison Service following sentencing (MoJ, 2010). Whilst these findings attend to

2

This UK study defined mental health as a severe and enduring mental illness as utilised by community
mental health teams. This may account for the differential figure compared to studies who use a more
generalised mental health problem as their source of classification.

more severe mental health problems, previous data considering 11 different diagnoses from
psychosis and personality disorder to more mild symptoms and presentations such as sleep
difficulties and worries, indicates 33% of male offenders in custody suffered from depression (this
was higher for women and those on remand) and 64% of sentenced male offenders had a
personality disorder (Singleton, Meltzer, Gatward, 1998). Women are consistently shown to have a
higher prevalence of mental illness in offending samples alongside higher rates of self harm and
suicide. Women prisoners account for 30% of all incidents of self-harm despite representing just 5%
of the total prison population. In addition, 46% of women prisoners reported having attempted
suicide at some point in their lives. This is more than twice the rate of male prisoners (21%) and
higher than in the general UK population amongst whom around 6% report having ever attempted
suicide (Ministry of Justice, 2013).
Furthermore over 50% of the prison population admits to using at least one drug in the year before
coming to prison (32% of sentenced men noted severe dependence before entering prison) and 48%
of sentenced male prisoners admitted to using drugs during their sentence (Singleton, Farrell &
Meltzer, 2003). Female prisoners report more Class A drug use in the four weeks before custody
than male prisoners, and were also more likely to report that their offending was to support
someone elses (as well as their own) drug use (Ministry of Justice, 2013). Dual diagnosis is well
established with substance misuse recognised as the most common co-morbid disorder to occur
with severe mental illness (Drake, et al. 2001). In one national sample of offenders, dependence on
opiates or stimulants increased the likelihood of having a personality disorder by six times (Singleton
et al., 2003). In his review of prison drug treatment, Lord Patel noted that dual diagnosis should be
considered the norm rather than the exception (2010).
Additionally, a correlation between learning difficulties and substance misuse is also emerging, with
60% of individuals with learning difficulties estimated to have a substance misuse problem (Crocker
et al., 2007a). Overall, whilst it can be seen that offenders with either a learning difficulty, substance
misuse problem or mental health problem are highly prevalent, notwithstanding the difficulty in
definition, there is also an acknowledgment that the co-occurrence of such problems is
overrepresented in the criminal justice system (Osher, 2008). There is a need to replicate the large-
scale investigation of the psychiatric morbidity in prisoners as conducted by Singleton et al., (1998)
with a view to including learning disability and attending to other points in the criminal justice
journey (Bradley, 2009).

4. IDENTIFICATION
4.1 The tools of identification
Identifying individuals with complex needs is vital to the next steps in their treatment and
management (Bradley, 2009). This said, identification is often the first stumbling block in the process
of working with offenders with complex needs and presents a barrier to the provision of accurate
prevalence rates as well as adequate and appropriate treatment.
Identifying offenders with mental health disorders is usually undertaken by health care professionals
using strict diagnostic criteria as set out by the DSM. This is useful if an offenders mental health
meets the threshold for formal diagnosis, but may be less helpful if offenders are suffering from
mental health problems such as depression that do not meet clinical criteria. Where this occurs,
referrals to services other than in-reach teams may be appropriate.
With regards to substance misuse identification, this is often through self-report and criminal justice
agencies use a range of screening tools. Although self-report data has been queried in the past,
comparisons with biomarkers, qualitative interviews and criminal records show it is a reliable
method for identifying drug and alcohol use (Darke, 1998).
The Treatment Outcome Profile (TOP; Marsden et al., 2008) represents a reliable and valid tool for
measuring outcomes of treatment and feeds into National Drug Treatment Monitoring System
(NDTMS) data. There are four domains that form its focus; substance use, health, crime and social
functioning, reflective of the holistic evaluation of treatment, moving beyond drug use. Although
this has also traditionally remained in the community environment, local councils in Essex are
piloting its suitability within the prison domain to further ensure seamless information sharing. Use
of the Drug Abuse Screen Test (DAST; Skinner, 1982) has also been incorporated when identifying
drug misuse in police custody (McGilloway & Donnelly, 2004) and this has been correlated with the
DSM diagnosis of substance dependence (Gavin, Ross & Skinner, 1989).
The Alcohol Use Disorder Identification Test (AUDIT) developed by the World Health Organisation
has been utilised in offender samples also. MacAskill et al., (2012) found that the AUDIT could be
utilised and administered by trained prison officers to identify needs in new admissions to prison.
More recently, the AUDIT has been found to have good predictive validity of drinking behaviour
following release of offenders from prison (Thomas, Degenhardt, Alati & Kinner, 2014). The
shortened version, the AUDIT C is also used by third sector drug and alcohol organisations in Essex
who may work with offender samples. Scores on the AUDIT are able to identify the level and nature
of drinking (assessing for dependency) and as such, inform health care providers about the tier and
level of treatment that is appropriate for that offender.

Identifying offenders with learning disabilities is more complex and the prevalence of such
individuals may be underestimated. Learning disability services may not be aware of, or under-
report, criminal activity. Similarly individuals already in the criminal justice system may be less
inclined to admit to having these difficulties for fear of bullying or victimisation (Loucks, 2007). With
regards to tools for identification, learning disability can be identified using validated psychometric
measures such as the Wechsler Adult Intelligence Scale (WAIS-IV; Wechsler, 2008). Whilst such a
tool considers multiple elements of functioning and gives a full scale IQ measure, it is lengthy to
administer, requires specialist skills and training and therefore may only be appropriate if an
offender is already suspected of having an intellectual impairment rather than being conducted
routinely at different entry points within the criminal justice system.
The abbreviated version, the Wechsler Adult Abbreviated Scale of Intelligence (WASI; Wechsler,
1999) can overcome some of the difficulties of duration of assessment but as a result is not a
comprehensive tool and has been criticised for its inability to distinguish between specific learning
disabilities. Although the Wechsler scales have been used within forensic populations (e.g. Langevin
& Curnoe, 2008), the fact they can only be administered by a professional trained in this proficiency
limits their ability to be used on a national and regular scale, e.g. routinely on entry to prison or
police custody. The Learning Disability Screening Questionnaire (LDSQ; McKenzie & Paxton, 2006)
overcomes this problem as it can be administered by someone who knows the recipient well or
indeed by individuals themselves. This level of flexibility is advantageous in criminal justice settings.
The validity of the LDSQ has recently been assessed in forensic settings and populations and has
received favourable review demonstrating specificity, sensitivity and discriminative validity
(McKenzie, Michie, Murray & Hales, 2012).
This said, specificity was found to be lower in forensic populations than general samples, which
indicates a risk of this tool not reliably identifying an individual with a learning disability. Further
research is required to consider the extension of the LDSQ to a wider sample and increase certainty
in its utility in forensic settings although these initial results are promising. Other available tools
include the Learning Disabilities in the Probation Service scale (LIPS; Mason & Murphy, 2002) which
has been utilised in community samples (Mason & Murphy, 2002b) and the Hayes Ability Screening
Index (HASI; Hayes, 2000). As intellectual disability extends beyond IQ scores, the Vineland Adaptive
Behaviour Scales can assess adaptive functioning (Sparrow, Bella & Cicchetti, 1984) useful for
treatment decisions in offending cohorts (Keeling, Beech & Rose, 2007). Whilst these tools exist
however, there is not a consensus or routine application of these across different criminal justice
settings.

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5. RELATIONSHIP WITH OFFENDING

5.1 Substance misuse, learning disability, mental illness and offending
Although learning disability, mental illness and substance misuse occur frequently in the offending
population, it is also important to consider the impact such needs have on ones behaviour and
whether this contributes to recidivism.
Drug users have been noted to be three to four times more likely to commit crime than non-drug
users (Bennett, Holloway & Farrington, 2008), with heroin and crack users particularly responsible
for a disproportionate amount of acquisitive crime (e.g. theft, burglary, robbery) (Bukten et al.,
2011; Makkai, 2001; McIntosh, Bloor & Robertson, 2007). This highlights the need for the treatment
and rehabilitation of substance misusing offenders. The National Treatment Agency (NTA) estimates
that for every substance misusing offender not in treatment, this costs society 26,074 per year
based on the number of offences likely to be committed (NTA, 2012). Similarly they estimated that
drug treatment prevented an estimated 4.9 million crimes in 2010-2011 not least because of the
impact drug treatment is said to have on reconviction rates (up to 47% decrease, NTA, 2012b).
Alcohol too has historically been linked with an increased risk of offending ranging from antisocial
behaviour, violence and homicide (Bellis, Hughes & Hughes, 2005). In addition, consumption of
alcohol has been noted to make individuals more vulnerable to becoming a victim and a perpetrator
of interpersonal violence (Abramsky et al., 2011). The legality of alcohol means its impact is far-
reaching and prevalent individuals who engaged in pre-drinking before a night out were 2.5 times
more likely to be involved in a fight (Hughes, Anderson Morleo & Bellis, 2008). Whilst these
altercations may not have resulted in a criminal conviction, there are clear societal and economic
implications.
Considering offending and mental health, schizophrenia (Fazel, Gulati, Linsell, Geddes & Grann,
2009) as well as psychosis (Douglas, Guy & Hart, 2009) has been linked to an increased risk of
violence to others. This risk is increased further where substance misuse is an issue, with researchers
once again heralding the treatment of substance misuse as an all important factor in reducing
offending in this population (Fazel et al., 2009; Walsh, Buchanan & Fahy, 2002). As such, although
the link between mental health and offending is noteworthy, it is also important to acknowledge
that the proportion of violent crime in society as a whole attributable to those with schizophrenia is
less than 10% (Walsh et al., 2002). Risk of homicide in psychosis is considerably lessened after
treatment which again highlights the need for early identification and intervention (Nielssen &
Large, 2010).

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Turning to the link between learning disability and offending, a prospective study in the UK found
that sexual offending and arson were over-represented in a cohort of intellectually disabled
offenders3 , violent offences were more prevalent amongst these individuals and offending began at
an earlier age (Barron, Hassiotis and Banes, 2004). Arson has been noted as an offence particularly
correlated with learning disability elsewhere (e.g. Alexander, Piachaud, Odebiyi & Gangadharan,
2002) perhaps because of its association with limited interpersonal contact that offenders with
learning disabilities may be keen to avoid. In addition, learning disability and sexual aggression has
also been linked through poor social and interpersonal skills (Craig et al., 2006), poor impulse control
and a lack of understanding about the illegality of sexual offending (Keeling & Rose, 2012). As such,
although there is a high prevalence of sexual offending within learning disabled offender cohorts,
this may not be due to deviant sexual preferences (Camilleri & Quinsey, 2011). Furthermore, due to
their validation with non-learning disabled populations, traditional risk assessments such as the
Rapid Risk Assessment for Sexual Recidivism (RRASOR; Hanson, 1997) have been difficult to apply to
learning disabled cohorts which mean ascertaining an accurate prediction of risk is problematic
(Hanson, Sheahan & VanZuylen, 2013).
Attending to co-occurrence of disorders and offending, a link between substance misuse, learning
difficulty and offending behaviour is becoming more established (McGillivray & Moore, 2001;
Murphy & Mason, 2014). Individuals with learning difficulties and severe mental health problems
have also been shown to be more likely to demonstrate violence and be arrested (Crocker, Mercier,
Allaire & Roy, 2007) and offenders with intellectual disability have been seen to have more
prevalence of probable psychosis (Hassiotis et al., 2011).
Such evidence highlights the urgency in considering offenders with complex needs, particularly with
regards to minimising risk to the public and further offending behaviour.

This study utilised the definition of an IQ under 80 and considered offending to mean any contact with the
criminal justice system, even if this was just police arrest without conviction.

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6. SERVICE USER PERSPECTIVES

6.1 The experience and perception of the criminal justice system by
offenders with complex needs
Substance misusing offenders report a level of stigma projected towards them from wider society,
other offenders and other drug users (Rhodes et al., 2007; Rdner, 2005; Simpson, 2003). As a
result, substance misusing offenders assimilate a pronounced level of shame and guilt which can
often propel further use. Isolated recovery wings in prison settings can shield individuals from such
stigma in the sense they are located with other users, however they may still be subject to prejudice
and stigma from the general population within the prison. Prisoners have reported however that
they prefer a segregated drug recovery wing especially when queuing to collect their substitute
prescriptions (Senker, unpublished).
The experience of the criminal justice system and process extends beyond prison. Post release has
been highlighted as a particular time of difficulty and vulnerability for offenders with mental health
problems (Binswanger et al., 2011). Furthermore, offenders in forensic hospitals articulated that
stigma was felt more acutely due to the duality of being an offender and having a mental health
difficulty, which was problematic for recovery efforts (Mezey et al., 2010). For prisoners with mental
health problems, there is a subjective perception of needs being unmet, in particular; a lack of
daytime activities and resolution of psychotic symptoms or psychological distress (Harty, Jarrett,
Thornicroft & Shaw, 2012). The number of perceived unmet needs is greater in offenders on health
care wings in prisons than offenders in secure hospitals and mentally unwell offenders in prison
report higher levels of dissatisfaction with services (Thomas, 2005).
Prisoners with learning disabilities are more likely to report a lack of social support and have a higher
frequency of attempted suicide and self-harm (Hassiotis et al., 2011). Learning disabled prisoners
found it hard to make themselves understood, were more likely to have been restrained and missed
out on elements of the prison regime such as visits and gym attendance due to lack of understanding
about the process or difficulties completing requests. This may be misinterpreted as bad or
disruptive behaviour by prison staff (Talbot, 2008). Much of the challenges described in prison may
be related to a lack of desire to highlight difficulty in understanding for fear of bullying or
victimisation (Loucks, 2007). Individuals with learning disabilities admitted to psychiatric wards
reported feeling vulnerable and scared upon admission with a lack of understanding about why they
need to take medication, as such an integrated facility was advocated whereby beds for learning
disabled individuals were allocated within the psychiatric unit (Parkes, Samuels, Hassiotis, Lynggard
& Hall, 2007). Furthermore, individuals with a mild learning disability report a sense of
powerlessness and confusion as to whether they were being cared for or punished when detained

13

under the Mental Health Act (McNally, Beail & Kellett, 2007). It is important to note experiences of
those in secure units are not wholly negative (Carlin, Gudjonsson & Yates, 2005).
Although the cited research is not specifically with offenders, the correlation between mental
health, learning disability and offending means some individuals may have committed offences and
not been charged or convicted. This research also consolidated the importance of seeking the
opinions and experiences of service users when developing services, a sentiment echoed elsewhere
in provisions for individuals with psychosis and learning disabilities (Hemmings, Underwood &
Bouras, 2009). Despite this, the literature in the field of service user perspectives in forensic mental
health has been noted as limited (Coffey, 2006).

7. IMPROVEMENTS
7.1 Recommendations for best practice areas for improvement
The importance of identifying offenders with complex needs cannot be minimised and has been
highlighted by several Government papers in recent times (e.g. Bradley, 2009; Corston, 2007; Patel,
2010; Home Office, 2001).
In his evaluation on drug treatment in prison and upon release, Lord Patel (2010) made several
recommendations about the future of supporting substance misusing offenders. These included:

Individualised treatment plans offering intervention to the right person at the right time and
in the right way

Integrated pathways between prison and community

A focus on reintegration and resettlement

A recovery paradigm with service users at the very heart of it.

Considering treatment for offenders with mental health problems, despite the frequency of dual
diagnosis, services rarely cater for individuals presenting with both issues4, resulting in a disparate,
unintegrated system which may be difficult for individuals to navigate. This has prompted calls for
an integrated, unified service which can cater for and treat both problems simultaneously under
one roof (Bradley, 2009; Brooker et al., 2014; Drake et al., 2001). Innovations in US practice have
seen specialised probation officers trained to supervise offenders with mental health problems,
although this has not been replicated yet in the UK (Brooker et al., 2014).
Furthermore, although mental health in-reach teams in prison were a promising and welcome
addition to the criminal justice system and represented a merging between punishment and health,
there remains a need for diversion and intervention at earlier points in the criminal justice process

4

Only 5% of 105 prisons had a specific dual diagnosis service (Forrester et al., 2013).

14

(Forrester, Chiu, Dove & Parrott, 2010). Prison in-reach teams are under considerable pressure and
do not operate in the way they were originally intended, often offering primary and tertiary care
rather than just secondary. In-reach teams are unique in that they operate neither in a community
nor hospital setting but are required to do similar work, albeit with an increased case load and
fewer staff (Forrester et al., 2010). In a recent survey of 105 prisons in the UK, each nurse was seen
to cover approximately 500 prisoners, 29% of prisons had no consultant cover and only 24% had
access to a dedicated psychologist (Forrester et al., 2013). This places considerable pressure on
healthcare professionals attending to mentally unwell offenders and impacts the level and amount
of care able to be offered. Forrester and colleagues (2013) note that the identification of mentally
unwell offenders at the point of entry into prison needs considerable improvement and revision,
with the current screening protocol seemingly insufficient. Bradley (2009) urged that the prison
health screen be evaluated and the assessment of learning disability be incorporated. This is of
particular importance when imprisonment disturbs community mental health support, highlighting
the need for continuous, integrated services between prison and community incorporating
information sharing and continual assessment (Byng et al., 2012). Furthermore the distribution of
in-reach services across UK prisons shows much variation and disparity as such treatment received
by prisoners is not uniform, being compared to a postcode lottery (Forrester et al., 2013).
Recommendations have been made with regards to offenders with learning difficulties to improve
staff training, increase opportunities for diversion from prison and the criminal justice system as a
whole as well as improve community support for offenders with learning difficulties (Hayes, 2007).
Qualitative interviews with offenders themselves reveals a desire for less complex language
throughout the criminal process. The court experience can be intimidating and few offenders have
their needs appropriately delineated in pre-sentence reports with implications for sentencing (HM
Inspectorate, 2014). Although an appropriate adult should be offered to individuals in police
custody, less than a third receive this (Talbot, 2008). Although training has been noted for criminal
justice professionals in the identification and treatment of mental illness, this has not been
replicated in the domain of learning disabilities (Barron et al., 2004). This is particularly imperative
for prison officers who are on the front line and have the most contact with offenders (Bradley,
2009). Staff training is a vital component in the identification and awareness of learning disabilities
in order to implement early diversion and treatment. Screening services in police custody suites
need to be more consistent as well as provide access to previous treatment episodes (Bradley,
2009). Custody sergeants reported confusion over mental health problems and mental capacity and
it was identified that the open plan nature of many custody suites impacts the desire to disclose
learning difficulties on arrest. Having a screened off booking in area might be one way of
overcoming this observation (HM Inspectorate, 2014). Further, those leaving prison who have
mental health and or learning disabilities who are not subject to probation orders can be neglected
15

their care needs to be continuous despite leaving the criminal justice domain. A mentoring service
has been advocated as one way of overcoming this treatment gap (Bradley, 2009) which is important
in light of feedback from prisoners with intellectual disabilities who did not know who or where they
could turn to upon release (Talbot, 2008).

8. WHAT WORKS
8.1 The existence of modified programmes for offenders with complex
needs
The existence of modified programmes for offenders with complex needs consolidates
recommendations of early identification in order for specified and tailored treatment. Clearly the
implications of identifying individuals with complex needs is limited if no forms of specialised care or
treatment are practised thereafter. Risk, need and responsivity principles in forensic psychology
highlight the importance in tailoring treatment to individuals specific needs, learning abilities and
style in order to make treatment most effective (Andrews et al., 1990).
Prisons recognise the need to support individuals with substance misuse problems through the
utilisation and employment of recovery based wings, integrated drug treatment services,
pharmacological support and counselling, assessment, referral and advice through services (CARAT
teams). Prisoners Addressing Substance Related Offending (P-ASRO) (McMurran & Priestly, 2003) is
one cognitive behavioural based programme, designed specifically for substance misusing offenders.
Currently employed across the prison estate, the programme aims to reduce offending though a
decrease in drug-taking, appreciating the drug-crime link previously discussed. P-ASRO has seen
short-term success in offending populations (Crane & Blud, 2012). Whilst the data show an
improvement in moving towards action (Stages of Change, Prochaska & DiClemente, 1983), less
impulsivity and greater problem solving ability, P-ASRO needs to be tested with regard to specific
substances and reconviction data in order to fully assess its contribution and worth. Furthermore, P-
ASRO targets individuals with low to medium dependency despite the acknowledgement that
forensic clients usually meet the criteria for more severe, high dependence (Crane & Blud, 2012).
Mental health in-reach teams exist in prisons, although there is considerable disparity across these
services (Forrester et al., 2013), and many prisons have specialised healthcare wings which focus on
the treatment and accommodation of mentally unwell prisoners. Examples of modified programmes
for mentally ill offenders include programmes for firesetting (Swaffer, Haggett & Oxley, 2001) and
more general offender behaviours and thinking styles, such as the modified reasoning and

16

rehabilitation programme (Young & Ross, 2007)5. The need to adapt programmes for offenders with
specific mental health problems (e.g. psychopathy) is imperative as consolidated by high drop-out
rates within this cohort (Cullen, Soria, Clarke, Dean & Fahy, 2011).
Research on modified programmes for offenders with learning disabilities exists but is relatively
limited in comparison to programme evaluations for mainstream offenders. Where research does
exist this largely falls within the domain of sex offending, perhaps attributable to the over-
representation of learning disability within this offence category. Modified programmes generally
constitute amendments to mainstream programmes in order to attend to cognitive impairments
rather than considering differential reasons for offending (Craig & Hutchinson, 2005).
Sexual education courses have also been implemented to consider poor or limited sexual knowledge
in learning disabled offenders (Lindsay, Bellshaw, Culross, Staines & Michie, 1992). Adapted
programmes have been reported to build on the repetitions of simply presented, pictorial
information eliminating and avoiding complex language and information whilst still focusing on
victim empathy and cognitive behaviour elements (Craig et al., 2006). The use of role plays is also
advocated in modified programmes as well as greater time allowed for information to be processed
(Lindsay & Smith, 1998). This can take the form of shorter sessions but with a longer group
programme length overall (Keeling & Rose, 2012). Feedback on, and validation of, modified sexual
offender programmes usually comes in the form of case-study reports and therefore it is difficult to
gauge the generalised impact of such programmes as well as their impact on recidivism. Findings do
demonstrate improvements on attitudes consistent with offending, increased self-control and sexual
knowledge (Rose, Rose, Hawkins & Anderson, 2012).
Despite small sample sizes, it seems sensible to modify treatment programmes to cater for the
nuanced causation of, and pathways to, offending - particularly in sexual aggression with learning
disabled offenders. Placing learning-disabled offenders in a group with sexually deviant and
pathological offenders may be detrimental for their wellbeing and could actually exacerbate
offending behaviour. Recent research has reported on the positive influence of carrying out
modified sex offender programmes in the community and consulting speech and language therapists
in the design and implementation such programmes (Rose et al., 2012). Programmes have also been
modified for learning disabled offenders in the domains of arson (Taylor, Thorne, Robertson &
Avery, 2002) and anger (Burns, Leach & Higgins, 2003), both within forensic secure units.
Recent meta-analyses into cognitive behavioural therapy for anger in adults with learning disabilities
acknowledged the need for comparison control groups and larger sample sizes (Nicoll, Beail & Saxon,
2013; Vereenooghe & Langdon, 2013). However, these investigations did not specifically consider

5

This is not UK based but still demonstrates the importance and utility of adapting programmes for offenders
with complex needs.

17

offender samples. Whilst research on modified behaviour programmes for offenders with learning
disabilities requires further replication and development, recognition of the need to modify such
programmes is encouraging for offenders with complex needs.

9. CONCLUSIONS & CONSIDERATIONS

This literature review has identified the difficulty in identifying offenders who present with
substance misuse, mental health problems and/or learning disabilities, not least because of the
spectrum of difficulties covered in the range of definitions applied to this cohort. Effective
identification of such individuals is imperative in order to ensure effective, appropriate and
timely care.

The Corston Report (2007) highlights the need for a distinct, radically different, visibly-led,
strategic, proportionate, holistic, woman-centred, integrated approach

A jointly agreed and adopted definition between agencies involved in the criminal justice system
could be beneficial.

Considering the experiences of offenders with complex needs adds weight to this argument as
they report stigma, a lack of understanding about the criminal justice process, bullying, isolation
and victimisation.

In addition, the correlation between offending and these needs means that investing in
identification and treatment of offenders with complex needs holds great potential societal and
economical value.

Recommendations from a range of sources, academic and government papers, indicates multi-
agency working is vital.

Individual needs should be identified from the outset, starting at the point of arrest, using
effective, validated and reliable tools.

Information about such needs should influence treatment options and allow consideration of a
range of sentences (including bail and community orders) in light of evidence on the
vulnerability of offenders with complex needs in custody.

Support for these needs should be continuous throughout the criminal justice process enhanced
by sharing of information between agencies, to avoid duplication and promote collaboration.

Once individuals are identified, tailored and adapted treatment should ensue permitting access
to the same level of treatment as mainstream offenders.

Staff should be trained in order to feel competent in identifying, assessing and treating offenders
with complex needs. This is of particular importance for prison officers and other front-line
criminal justice staff, such as those operating in police custody suites, probation and in the
community with offenders on release from prison.
18

Offenders with complex needs can provide invaluable feedback about the degree their needs are
being met and should be utilised as a service evaluation and development tool, being consulted
wherever possible.

Reports such as Patel (2010), Bradley (2009) and the No-one knows literature are critical in
identifying gaps in service provision, however their recommendations must be acted upon in
order to secure effective support for offenders with complex needs.

In essence, the mantra of no-one knows should be transformed in to everyone knows with
professionals also knowing what to do about it (Jones & Talbot, 2010).

19

REFERENCES
Abramsky, T., Watts, C. H., Garcia-Moreno, C., Devries, K., Kiss, L., Ellsberg, M., ... & Heise, L. (2011).
What factors are associated with recent intimate partner violence? Findings from the WHO multi-
country study on women's health and domestic violence. BMC public health, 11, 109.
Alexander, R., Piachaud, J., Odebiyi, L., & Gangadharan, S. (2002). Referrals to a forensic service in
the psychiatry of learning disability. The British Journal of Forensic Practice, 4, 29-33.
American Psychiatric Association (2012) Diagnostic and Statistical Manual of Mental Disorders.
Retrieved from http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=569 on
30th May 2012.
Andrews, D. A., Zinger, I., Hoge, R. D., Bonta, J., Gendreau, P., & Cullen, F. T. (1990). Does
Correctional Treatment Work? A Clinically Relevant and Psychologically Informed Meta-Analysis.
Criminology, 28, 369-404.
Barron, P., Hassiotis, A., & Banes, J. (2004). Offenders with intellectual disability: a prospective
comparative study. Journal of Intellectual Disability Research, 48, 69-76.
Bellis, M. A., Hughes, K., & Hughes, S. (2005). Alcohol and interpersonal violence, policy
briefing. Rome: World Health Organization.
Bennett, T., Holloway, K., & Farrington, D. (2008). The statistical association between drug misuse
and crime: A meta-analysis. Aggression and Violent Behavior, 13(2), 107-118.
Binswanger, I. A., Nowels, C., Corsi, K. F., Long, J., Booth, R. E., Kutner, J., & Steiner, J. F. (2011).
From the prison door right to the sidewalk, everything went downhill, A qualitative study of the
health experiences of recently released inmates. International journal of law and psychiatry, 34, 249-
255.
Bradley, K. (2009). Lord Bradleys review of people with mental health problems or learning
disabilities in the criminal justice system. London: Home Office.
Brooker, C., Denney, D., & Sirdifield, C. (2014). Mental disorder and probation policy and practice: a
view from the UK. International journal of law and psychiatry [awaiting page numbers].
Brooker, C., Sirdield, C., Blizard, R., Denney, D., & Pluck, G. (2012). Probation and mental illness. The
Journal of Forensic Psychiatry and Psychology, 23, 522537
Bukten, A., Skurtveit, S., Stangeland, P., Gossop, M., Willersrud, A. B., Waal, H., Clausen, T. (2011).
Criminal convictions among dependent heroin users during a 3-year period prior to opioid
maintenance treatment: A longitudinal national cohort study. Journal of Substance Abuse Treatment.

20

Burns, M., Bird, D., Leach, C., & Higgins, K. (2003). Anger management training: the effects of a
structured programme on the self-reported anger experience of forensic inpatients with learning
disability. Journal of Psychiatric and Mental Health Nursing, 10, 569-577.
Byng, R., Quinn, C., Sheaff, R., Samele, C., Duggan, S., Harrison, D., et al. (2012). COCOA: Care for
offenders, continuity of access. London: National Institute for Health Research, Queen's Printer and
Controller of HMSO.
Camilleri, J. A., & Quinsey, V. L. (2011). Appraising the risk of sexual and violent recidivism among
intellectually disabled offenders. Psychology, Crime & Law, 17, 59-74.
Carlin, P., Gudjonsson, G., & Yates, M. (2005). Patient satisfaction with services in medium secure
units. Journal of Forensic Psychiatry & Psychology, 16, 714-728.
Coffey, M. (2006). Researching service user views in forensic mental health: A literature review. The
Journal of Forensic Psychiatry & Psychology, 17, 73-107.
Corston, B. J. (2007). The Corston Report: A Report of a Review of Women with Particular
Vulnerabilities in the Criminal Justice System. Home Office.
Craig, L. A., & Hutchinson, R. B. (2005). Sexual offenders with learning disabilities: Risk, recidivism
and treatment. Journal of Sexual Aggression,11, 289-304.
Craig, L. A., Stringer, I., & Moss, T. (2006). Treating Sexual Offenders With Learning Disabilities in the
Community A Critical Review. International Journal of Offender Therapy and Comparative
Criminology, 50, 369-390.
Crane, M. & Blud, L. (2012). The effectiveness of Prisoners Addressing Substance Related Offending
(P-ASRO) programme: evaluating the pre and post treatment psychometric outcomes in an adult
male Category C prison. British Journal of Forensic Practice, 14, 49-59.
Crocker, A. G., Ct, G., Toupin, J., & St-Onge, B. (2007a). Rate and characteristics of men with an
intellectual disability in pre-trial detention. Journal of intellectual and developmental disability, 32,
143-152.
Crocker, A. G., Mercier, C., Allaire, J. F., & Roy, M. E. (2007b). Profiles and correlates of aggressive
behaviour among adults with intellectual disabilities. Journal of Intellectual Disability Research, 51,
786-801.
Cullen, A. E., Soria, C., Clarke, A. Y., Dean, K., & Fahy, T. (2011). Factors predicting dropout from the
reasoning and rehabilitation program with mentally disordered offenders. Criminal Justice and
Behavior, 38, 217-230.

21

Darke, S. (1998). Self-report among injecting drug users: a review. Drug and alcohol dependence, 51,
253-263.
Department of Health. (2001). A new strategy for learning disability for the 21st century. A White
Paper. Department of Health: London.
Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff, K., Kola, L.,... & Rickards, L. (2001).
Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52,
469-476.
Fazel, S., Gulati, G., Linsell, L., Geddes, J. R., & Grann, M. (2009). Schizophrenia and violence:
systematic review and meta-analysis. PLoS medicine, 6.
Forrester, A., Chiu, K., Dove, S., & Parrott, J. (2010). Prison health-care wings: Psychiatry's forgotten
frontier? Criminal Behaviour and Mental Health, 20, 51-61.
Forrester, A., Exworthy, T., Olumoroti, O., Sessay, M., Parrott, J., Spencer, S. J., & Whyte, S. (2013).
Variations in prison mental health services in England and Wales. International journal of law and
psychiatry, 36, 326-332.
Gavin, D. R., Ross, H. E., & Skinner, H. A. (1989). Diagnostic validity of the Drug Abuse Screening Test
in the assessment of DSM-III drug disorders. British journal of addiction, 84, 301-307.
Grant, B.F., Harford, T.C, Muthen, B.O, Yi, H-Y., Hasin, D.S & Stinson, F.S., (2007). DSM-IV alcohol
dependence and abuse: further evidence of validity in the general population. Drug and Alcohol
Dependence, 86,154-166.
Hanson, R. K. (1997). The development of a brief actuarial risk scale for sexual offence recidivism
(User Report 97-04). Ottawa: Department of the Solicitor General of Canada.
Hanson, R. K., Sheahan, C. L., & VanZuylen, H. (2013). STATIC-99 and RRASOR Predict Recidivism
among Developmentally Delayed Sexual Offenders: A Cumulative Meta-Analysis. Sexual Offender
Treatment, 8 (1).
Harty, M., Jarrett, M., Thornicroft, G., & Shaw, J. (2012). Unmet needs of male prisoners under the
care of prison Mental Health Inreach Services. Journal of Forensic Psychiatry & Psychology, 23, 285-
296.
Hassiotis, A., Gazizova, D., Akinlonu, L., Bebbington, P., Meltzer, H., & Strydom, A. (2011). Psychiatric
morbidity in prisoners with intellectual disabilities: analysis of prison survey data for England and
Wales. The British Journal of Psychiatry, 199, 156-157.

22

Hemmings, C., Underwood, L., & Bouras, N. (2009). What should community services provide for
adults with psychosis and learning disabilities? A comparison of the views of service users, carers
and professionals. Advances in Mental Health and Learning Disabilities, 3, 22-27.
Hayes, S. C. (2000). Hayes Ability Screening Index (HASI). Sydney, Department of Behavioural
Sciences in Medicine, University of Sydney.
Hayes, S., Shackell, P., Mottram, P. & Lancaster, R. (2007). The prevalence of intellectual disability in
a major UK prison. British Journal of Learning Disabilities, 35, 162-167.
HM Inspectorate (2014). A joint inspection of the treatment of offenders with learning disabilities in
the criminal justice system. Retrieved from
https://www.justice.gov.uk/downloads/publications/inspectorate-reports/hmiprobation/learning-
disabilities-thematic-report.pdf on 6th June 2014.
Hughes, K., Anderson, Z., Morleo, M., & Bellis, M. A. (2008). Alcohol, nightlife and violence: the
relative contributions of drinking before and during nights out to negative health and criminal justice
outcomes. Addiction, 103, 60-65.
Jones, G., & Talbot, J. (2010). No One Knows: the bewildering passage of offenders with learning
disability and learning difficulty through the criminal justice system. Criminal Behaviour and Mental
Health, 20, 1-7.
Keeling, J. A., Beech, A. R., & Rose, J. L. (2007). Assessment of intellectually disabled sexual
offenders: The current position. Aggression and Violent Behavior, 12, 229-241.
Keeling, J. A., & Rose, J. L. (2012). Implications of the self-regulation model for treatment with sexual
offenders with intellectual disabilities. The British Journal of Forensic Practice, 14, 29-39.
Langevin, R., & Curnoe, S. (2008). Are the mentally retarded and learning disordered
overrepresented among sex offenders and paraphilics? International Journal of Offender Therapy
and Comparative Criminology, 52, 401-415.
Lindsay, W. R., Bellshaw, E., Culross, G., Staines, C., & Michie, A. (1992). Increases in knowledge
following a course of sex education for people with intellectual disabilities. Journal of Intellectual
Disability Research, 36, 531-539.
Lindsay, W. R., & Smith, A. H. (1998). Responses to treatment for sex offenders with intellectual
disability: a comparison of men with 1-and 2-year probation sentences. Journal of Intellectual
Disability Research, 42, 346-353.

23

Lord Patel (2010) The Patel Report: Reducing Drug-Related Crime and Rehabilitating Offenders:
Recovery and rehabilitation for drug users in prison and on release: recommendations for action.
HM Government; London.
Loucks, N. (2007). No One Knows: offenders with learning difficulties and learning disabilitiesreview
of prevalence and associated needs. Prison Reform Trust, London.
MacAskill, S., Parkes, T., Brooks, O., Graham, L., McAuley, A., & Brown, A. (2011). Assessment of
alcohol problems using AUDIT in a prison setting: more than an 'aye or no' question. BMC public
health, 11, 865.
Makkai, T. (2001). Patterns of recent drug use among a sample of Australian detainees. Addiction ,
96, 1799-1808.
Marsden, J., Farrell, M., Bradbury, C., Dale-Perera, A., Eastwood, B., Roxburgh, M., & Taylor, S.
(2008).
Development of the treatment outcomes profile. Addiction, 103, 1450-1460.
Mason, J., & Murphy, G. (2002). People with an intellectual disability in the criminal justice system:
Developing an assessment tool for measuring prevalence. British Journal of Clinical Psychology, 41,
315-320.
Mason, J., & Murphy, G. (2002b). Intellectual disability amongst people on probation: Prevalence
and outcome. Journal of Intellectual Disability Research, 46, 230-238.
McGillivray, J. & Moore, M. (2001) Substance use by offenders with mild intellectual disability.
Journal of Intellectual and Developmental Disability, 26, 297 310.
McGilloway, S., & Donnelly, M. (2004). Mental illness in the UK criminal justice system: a police
liaison scheme for mentally disordered offenders in Belfast. Journal of Mental Health, 13, 263-275.
Mcintosh, J., Bloor, M., & Robertson, M. (2007). The effect of drug treatment upon the commission
of acquisitive crime. Journal of Substance Use, 12, 375-384.
McKenzie, K., Michie, A., Murray, A., & Hales, C. (2012). Screening for offenders with an intellectual
disability: The validity of the Learning Disability Screening Questionnaire. Research in developmental
disabilities, 33, 791-795.
McKenzie, K. & Paxton, D. (2006). Promoting Access To Services: the development of a new
screening tool. Learning Disability Practice 9, 17-21.
24

McMurran, M., & Priestley, P. (2003). Prison Addressing Substance Related Offending (P-ASRO)
Selection Manual (Version 3 ), HMPS, London.

Ministry of Justice (2013) Gender differences in substance misuse and mental health amongst
prisoners, London: Ministry of Justice.
Ministry of Justice (2010). Statistics of Mentally Disordered Offenders 2008. England and Wales.
London: Home Office.
Mottram, P. and Lancaster, R. (2006) HMPs Liverpool, Styal and Hindley YOI: Preliminary Results.
Cumbria and Lancashire: NHS Specialised Services Commissioning Team.
Murphy, G., & Mason, J. (2014). Forensic and Offending Behaviours. In Handbook of
Psychopathology in Intellectual Disability (pp. 281-303). Springer New York.
National Treatment Agency (2012). Treat addiction, cut crime. Retrieved from

http://www.nta.nhs.uk/uploads/vfm-crimepresentationvfinal.pdf on 24th May 2014.

National Treatment Agency (2012b). The impact of drug treatment on reconviction. Retrieved from
http://www.nta.nhs.uk/publications.aspx?category=Criminal+Justice on 24th May 2014.

Nicoll, M., Beail, N., & Saxon, D. (2013). Cognitive Behavioural Treatment for Anger in Adults with
Intellectual Disabilities: A Systematic Review and Meta-analysis. Journal of Applied Research in
Intellectual Disabilities, 26, 47-62.

Nielssen, O., & Large, M. (2010). Rates of homicide during the first episode of psychosis and after
treatment: a systematic review and meta-analysis. Schizophrenia bulletin, 36, 702-712.
Osher, F. C. (2008). Integrated mental health/substance abuse responses to justice involved persons
with co-occurring disorders. Journal of Dual Diagnosis, 4, 3-33.
Parkes, C., Samuels, S., Hassiotis, A., Lynggaard, H., & Hall, I. (2007). Incorporating the views of
service users in the development of an integrated psychiatric service for people with learning
disabilities. British Journal of Learning Disabilities, 35, 23-29.
Prochaska, J.O. & DiClemente, C.C. (1983). Stages and processes of self-change of smoking: Toward
an integrative model of change. Journal of Consulting and Clinical Psychology, 51, (3), 390-395.
Rhodes, T., Watts, L., Davies, S., Martin, A., Smith, J., Clark, D., . . . Lyons, M. (2007). Risk, shame and
25

the public injector: A qualitative study of drug injecting in South Wales. Social Science & Medicine,
65(3), 572-585.
Rdner, S. (2005). I am not a drug abuser, I am a drug user: A discourse analysis of 44 drug users
construction of identity. Addiction Research & Theory, 13(4), 333-346.
Rose, J., Rose, D., Hawkins, C., & Anderson, C. (2012). A sex offender treatment group for men with
intellectual disabilities in a community setting. The British Journal of Forensic Practice, 14, 21-28.
Senior, J., Birmingham, L., Harty, M. A., Hassan, L., Hayes, A. J., Kendall, K., ... & Shaw, J. (2013).
Identification and management of prisoners with severe psychiatric illness by specialist mental
health services. Psychological medicine, 43, 1511-1520.
Senker, S. (2013). The impact of an integrated criminal justice system on the recovery journey of
substance misusing offenders. Unpublished Thesis: University of Essex.
Simpson, M. (2003). The relationship between drug use and crime: a puzzle inside an enigma.
International Journal of Drug Policy, 14(4), 307-319.
Singleton, N., Farrell, M., & Meltzer, H. (2003). Substance misuse among prisoners in England and
Wales. International Review of Psychiatry, 15, 150-152.
Singleton, N., Gatward, R., & Meltzer, H. (1998). Psychiatric morbidity among prisoners in England
and Wales. London: Stationery Office.
Skinner, H. A. (1982). The drug abuse screening test. Addictive behaviors, 7, 363-371.
Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). Vineland adaptive behavior scales: Interview
edition, survey form manual. Circle Pines, MN: American Guidance Service.
Steadman, H., Osher, F., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious mental
illness among jail inmates. Psychiatric services, 60, 761-765.
Swaffer, T., Haggett, M., & Oxley, T. (2001). Mentally disordered firesetters: a structured
intervention programme. Clinical Psychology & Psychotherapy, 8, 468-475.
Talbot, J. (2008). No One Knows: Report and Final Recommendations. Prisoners Voices: Experiences
of the Criminal Justice System by Prisoners with Learning Disabilities and Difficulties. Prison Reform
Trust.
Taylor, J. L., Thorne, I., Robertson, A., & Avery, G. (2002). Evaluation of a group intervention for
convicted arsonists with mild and borderline intellectual disabilities. Criminal Behaviour and Mental
Health, 12, 282-293.
26

Thomas, E., Degenhardt, L., Alati, R., & Kinner, S. (2014). Predictive validity of the AUDIT for
hazardous alcohol consumption in recently released prisoners. Drug and Alcohol Dependence, 134,
322-329.
Thomas, S. (2005). Inverse care? Comparing needs and satisfaction with services between prisoners
in healthcare centres and patients in medium secure units. Unpublished Thesis; Institute of
Psychiatry, Kings College London.

Vereenooghe, L., & Langdon, P. E. (2013). Psychological therapies for people with intellectual
disabilities: A systematic review and meta-analysis. Research in developmental disabilities, 34, 4085-
4102.
Walsh, E., Buchanan, A., & Fahy, T. (2002). Violence and schizophrenia: examining the evidence. The
British Journal of Psychiatry, 180, 490-495.
Wechsler, D. (2008). Wechsler Adult Intelligence ScaleFourth Edition (WAISIV). San Antonio, TX:
NCS Pearson.
Wechsler, D. (1999). Wechsler Abbreviated Scale of Intelligence: WASI. Psychological Corporation,
Harcourt Brace.
Young, S., & Ross, R. R. (2007). R&R2 for youths and adults with mental health problems: A prosocial
competence training program. Ottawa, ON: Cognitive Centre of Canada

27

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