Brain Injury and Offending: The Development and Field Testing of a Linkworker Intervention

The Role of the Linkworker

Linkworkers offer direct help to the prisoners referred to them by providing psychoeducation concerning brain injury and by helping the individuals to develop strategies to circumvent their brain injury–related deficits (Williams & Chitsabesan, 2016). This article describes the work of a Linkworker in an adult male prison.

Linkworkers work with prisoners who have screened positive for brain injury to develop a comprehensive assessment of their needs and to develop a support plan. They also help the prisoners to formulate their goals and to identify the steps required to meet them.

A key aspect of the Linkworker role, as the job title suggests, is to link with other staff and to be a resource for them, explaining the impact the brain injury may be having on the individual’s behaviour, how this may affect the interventions delivered by other teams, and the best ways of managing this and helping enhance the benefits by engaging with these teams. This liaison work occurs with external personnel as well as prison staff. The crucial test of efficacy of an intervention with prisoners is the extent to which it influences what happens once they are released. Trying to ensure a support system is in place for prisoners upon their release, including the provision of a discharge pack, is likely to be a critical part of this role.

Another part of the Linkworkers’ role is to liaise with agencies and families outside prison to provide strategies and guidance on how to support people with a brain injury when the individual is released, and to make the necessary referrals to neurology, physiotherapy, nurse specialists, mental health, housing, substance, social work, and other relevant stakeholders.

The Linkworkers also provide “through the gate” support for prisoners being released from prison into the local community. This involves the delivery of face-to-face or telephone support sessions that encourage the generalisation of strategies learned while in custody into the offenders’ home environment, and liaising with agencies in the community by making appropriate referrals and developing “portable profiles” that inform agencies of the individual’s history of brain injury and how this is likely to affect them (e.g., alerting Probation Officers to memory problems that could impact appointment attendance and, when appropriate, ensuring that support strategies are put in place).

Screening and Intervention

A summary of the intervention characteristics is provided in Table 1. New admissions to prison are screened for ABI using a standardised self-report measure, the Brain Injury Screening Index (BISI; Pitman et al., 2015). Those prisoners identified as having had a significant brain injury or multiple mild traumatic brain injuries are seen by the Linkworker. Injury severity is initially determined on the basis of the BISI results and the TBI Index, which is calculated by multiplying the number of injuries reported by the length of unconsciousness (LOC) of the most severe injury. Pitman and colleagues (2015) validated this index by demonstrating that higher levels of neuropsychological impairment were associated with higher scores on the Index. Typically, injuries are deemed as “significant” when they involve LOCs of 10 min or longer (Sherer, Struchen, Yablon, Wang, & Nick, 2008). The Linkworker then seeks confirmatory evidence for a history of brain injury in the individuals’ medical records (e.g., hospital discharge notes, Glasgow Coma Scale scores) and screens for problems likely to be associated with a brain injury. These include memory problems, problems with emotional regulation, impulsivity and disinhibition, and problems of social perception and social behaviour (Ponsford, Sloan, & Snow, 2013). Brief cognitive assessments may also be carried out if the individual has not recently been assessed, or when specific areas (e.g., executive function) have not been explored in routine assessments. Simple aids such as diaries and prompt cards using fixed routines to assist memory can be effective. Similarly for executive deficits, external structure or helping the individual to plan systematically can be effective.

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Table 1.

Intervention Characteristics.

Phases	Activities
Phase 1: Identifying a history and consequences of brain injury	Administration of the Brain Injury Screening Index (BISI; Pitman, Haddlesey, Ramos, Oddy, & Fortescue, 2015) Clinical interview Administration of questionnaires and standardised assessments exploring a range of areas, including history of brain injury, cognitive function, mood, and mental health.
Phase 2: Intervention in custody (The exact nature of the intervention is person-centred and tailored to individual needs.)	Individual  Setting of personal goals  Developing adaptive ways to cope with difficulties (psychoeducation, development and practice of compensatory strategies, therapy sessions) Environmental  Brain injury awareness training  Written behaviour support guidelines  Linking with specific services to provide support where needed
Phase 3: Follow-up after release	Establishing a relationship with relevant agencies (e.g., employment, housing) Assessment and intervention reports and letters to agencies, general practitioner, and next of kin, as required

Supervision

Linkworkers are managed on a day-to-day basis by a project leader with experience of working with brain injury and with a background in nursing. They also receive regular supervision from a clinical psychologist.

Case 1—VW

VW left school with no qualifications but attended a college where he trained as a bricklayer. He lived independently in a rented flat and was unemployed. Prior to his head injury, he had a diagnosis of attention deficit hyperactivity disorder (ADHD) and was prescribed methylphenidate. He reported a forensic history prior to his injury, including incidents of criminal damage, such as kicking fences. In 2013, VW was remanded in custody in relation to a violent offence. On remand, he completed the BISI and was identified as having sustained a TBI 2 years prior as a result of an alleged assault. Examination of clinical records revealed that VW had been admitted to hospital in 2010 following an unprovoked assault and that he had received 4 months of in-patient rehabilitation before being discharged to his mother’s care. On assessment, he was found to have below average memory, often forgetting names or appointments. He frequently misunderstood information that was given to him. He had a left-sided weakness rendering him unable to dress independently or to carry a tray. His cell mate helped him with these activities.

The Linkworker worked with VW for 6 months, helping him to use strategies to enable him to interpret correctly information given to him (Ponsford et al., 2013). He was encouraged to ask others to explain what they meant when he did not understand and to keep a journal of conversations (for example, with his solicitor, family, nurses, and prison staff). The Linkworker advised family members and professionals to provide information in small chunks, to be concrete, to ask VW to write information down, to confirm his understanding, and to explain further if he had misinterpreted information. The Linkworker referred VW to the Prison Physiotherapy Team, but due to his specific needs, they were unable to help. The Linkworker then liaised with the Community physiotherapy Team to ensure VW received a new splint and three monthly botulinum toxin injections for his left arm.

Before VW’s sentencing hearing, the Linkworker contacted the Community Social Work Team and the Specialist Continuing Care Team to present VW’s needs and to request funding for intensive brain injury rehabilitation. The Linkworker arranged for VW to be assessed by the consultant neuropsychologist at the local neurobehavioural rehabilitation centre, and this assessment of VW’s needs and recommendations was presented to the Court.

VW was given an 18-month suspended sentence on condition that he received intensive rehabilitation at the local neurobehavioural brain injury rehabilitation centre. The Judge stated that he believed VW would not receive the support he required if he were returned to prison.

At the rehabilitation centre, VW made good progress and was able to move on to a step-down, transitional living facility affiliated to the rehabilitation centre. There, he was responsible for making all meals, completing domestic activities, maintaining his own safety within the independent environment, and structuring his daily schedule. He joined a local gym and enjoyed building up his fitness and strength. He started learning to drive an adapted car, and served on an interviewing committee to select candidates for Linkworker posts.

After 6 months of intensive support, VW was able to live independently in a flat with minimal initial support from a physiotherapist, social worker, the Disabilities Trust Community Services, probation officer, and family.

Currently, VW continues to live independently, without formal support, and is able to dress, cook, and clean for himself and takes responsibility for his own finances. He has learned to use strategies to overcome his memory difficulties, he has a girlfriend, gained his driving licence, and his confidence in social situations has much improved. He sees his probation officer monthly and has help from his mother to do his shopping but no longer receives any other support.

Case 2—RR

RR screened positive for TBI on the BISI, where he reported a number of head injuries that resulted in loss of consciousness. He also reported having word finding difficulties, problems with concentration, and poor memory.

The first of these incidents had occurred 25 years earlier, and the Linkworker was able to obtain details of dates and hospital attendance. However, information about neurological examination, treatment, and follow-up was not available.

His offences concerned stealing cars and were committed to fund his drug habit. No violence was involved in his offending, although he had been assaulted.

Assessment by the Linkworker revealed slurred speech and a tendency to avoid eye contact. RR failed the finger nose test and showed a tendency to trip over his feet. The prisoner was concerned, as he had a family history of progressive neurological conditions. Upon collation of this information, the Linkworker referred RR to his general practitioner (GP) who referred on to a neurologist.

It was discovered that, before he was sent to prison, he was easily distracted at work and would forget what he was doing. He also had a tendency to do things in the wrong order but was helped by workmates to cover up his mistakes. The Linkworker introduced routines for tasks or jobs he was doing in the prison, using step-by-step methods and to-do lists (B. Wilson, Gracey, Evans, & Bateman, 2009). RR had a large laminated sheet with each step to follow in his cell, and a smaller laminated version in his pocket. He said this method helped a great deal. When he stopped using this method for a while, he floundered again.

The letters he wrote to his wife and daughter made no sense, apparently due to attentional difficulties. The Linkworker helped him to write letters in a quiet place and one line at a time (see Ponsford et al., 2013). Following this, his daughter reported that his letters were much easier to follow.

At work in the prison, if he became distracted, he was encouraged to use a checklist. RR was encouraged to take 5 to 10 min in his cell to get ready before leaving. RR also suffered from fatigue, so he was advised to take regular breaks and to do this whether he was feeling tired or not.

There was evidence that RR was not applying the memory strategies he had been taught in all relevant circumstances, so he needed support to develop these for each new situation (B. Wilson et al., 2009).

He gained a job as an “advisor” with a prison-based charity. He did well and achieved a qualification at the end of this. His role involved talking to prisoners near to their release. He was commended for his excellent work, especially his paperwork, which was said to be detailed, and of a very high standard.

At one stage, RR was transferred to another prison. However, the Linkworker ensured that he was transferred back, so that he would not miss his neurology appointments and lose his job.

A further concern was about how he would cope upon release. Before prison, he had avoided criminal behaviour for 8 to 9 years when he was supported by a partner. Prior to that period, he had been in and out of prison. His partner supported him in various ways, helping him with his finances and enabling him to work. He held down a job for 5 years and was in regular employment for an even longer period. When he and his partner separated, he became homeless and lived in a hostel. There, he slipped back into his previous drug-abusing lifestyle. When finally arrested, he claimed he was relieved, as he felt this saved him from addiction. He was worried that this pattern would recur upon his release if he had no support. He had difficulty managing his finances, and as he was not computer literate, he could not apply for his benefits online. To manage some of these risks, the plans for his release included ensuring he continued to play a role for the charity outside prison, which provided structure and purpose to his daily routine (Evans, 2009).

Case 3—MB

MB was identified by the BISI but would probably have been recognised through standard procedures, given his presentation. He was involved in a road traffic accident 10 years earlier and was in a coma for 10 weeks as a result of the TBI he sustained. He had a retrograde amnesia for the previous 8 years of his life. He was unable to remember his wife, his marriage, his home, or his dog. Following the accident, he was discharged home and his wife has been his full time carer ever since. He refused all other help, as he had no awareness of his deficits.

MB made a good physical recovery. He received a substantial personal injury award, although this was probably less than it would have been as he refused to accept care due to his lack of awareness. Since his TBI, he has not been able to work.

MB’s offence involved a serious common assault on his wife. He had a premorbid history of aggression, and he also served a prison sentence for grievous bodily harm (GBH) prior to his brain injury.

Since his injury, a recurring pattern had emerged whereby he would argue with his wife, leading to escalating violence against her. However, she and others were reluctant to press charges because of his TBI. This led to major concerns regarding his wife’s safety. She continued to be devoted to him but severely at risk. On admission to prison following a serious assault on her, he was extremely agitated, showed no awareness or remorse for what he had done, and expressed anger towards his wife.

MB was also at risk of being abused by other prisoners as he would make inappropriate comments, would easily get into a fight, and would be unable to de-escalate such situations. Due to considerations for his own safety, he often only spent 40 min over the course of a week out of his cell.

To ensure his safety, he was therefore transferred to the health care wing. There, he settled quickly, taking his medication (which he had resisted in the main wing). He got on well with staff and other prisoners, and behaved in a very friendly manner. He showed that he was capable of learning alternative responses to manage situations. Under these conditions, he posed no risk in prison, but concerns regarding his release home remained.

The role of the Linkworker involved seeing MB on a daily basis, but often just for a brief follow-up. Sometimes the Linkworker helped MB place orders for items such as clothes, or cigarettes, as he showed poor initiation and could not do this unaided. The Linkworker also developed support plans with staff. Once the Linkworker had enabled staff to see MB’s behaviour in terms of his brain injury, they became increasingly supportive. They previously believed something was wrong but did not know what. The Linkworker’s intervention enabled staff to understand MB better and work with him more effectively.

Support plans included basic guidelines (MB responded well to clear boundaries) and helping MB to organise himself and the tasks he needed to undertake. MB had a history of missing out on appropriate interventions for a variety of reasons, including forgetfulness and refusal.

The Linkworker intervention led to positive outcomes for MB while in custody. The Linkworker also managed to secure a place at a neurobehavioural rehabilitation centre for MB, but by the time funding was agreed for this, he had been released from prison without a court order made for him to receive rehabilitation. No follow-up information was available.