Development and validation of a peer support programme for the prisoners with mental and substance use disorders in India.

Background: The prevalence of mental health problems and substance use disorders is high in prisons. There is a need to develop effective and sustainable models in prison to address their mental health demands. Aim: The study aimed to develop and validate a peer support programme (PSP) for prisoners with common mental and substance use disorders (SUD). Method: The PSP was developed by reviewing the literature and expert interviews and validated by seven experts. Result: The expert interview brought out a total of 10 themes. The final components included in the content of the peer support interventions were information about mental health issues, identification of the cases, basic counseling skills, psycho-education, early warning signs and symptoms, managing substance use by motivational interviewing, and suicidal gatekeeping.
Conclusion: This study describes the development of a comprehensive PSP, and it needs to be tested to examine its feasibility and effectiveness in addressing mental health problems in prison settings. Copyright:

INTRODUCTION

The prevalence of mental health problems and substance use disorders (SUD) is high in prisons compared to the general population.[1] Despite the alarming rise in mental health issues among prisoners, availability and accessibility of treatment have often observed to be inadequate.[2] According to a prevalence study conducted in the Bangalore Central Prison (2011), 79.6% (n = 4002) of prisoners received a diagnosis of either mental illness or SUD.[3] Development of effective interventions for prisoners with mental and SUD will meet their mental health needs and catalyze transformation, thereby reducing recidivism.[4]

Studies conducted on the effectiveness of peer support interventions for persons with severe mental illness have found a positive association between peer support and hope, recovery, and empowerment at and beyond the end of the intervention.[5] Other reviews have also depicted that peer may be the next best alternative if there is a shortage of mental health professionals (MHP) in the prison.[6] However, there are no intervention studies in prison settings from India. As there is a severe shortage of MHPs in India, the concept of peer-led self-management support groups could be an effective solution in the prison setting. This study aimed to develop and validate a peer support programme (PSP) for prisoners with Common Mental Disorders (CMDs), SUDs, and suicidal ideations.

METHODS

The study was reviewed and approved by the institute ethics committee as a part of the PhD thesis of the first author and permission was obtained from the Department of Prisons and correctional services, Karnataka, for the study. Written informed consent was obtained from each respondent. The study registered in the Clinical Trials Registry-India (CTRI): No: CTRI/2019/06/019498.

The study sample included MHPs with more than 5 years of experience working with prisoners and convicted Prisoners (CTP) who had been in prison for more than 2 years.

The first author collected the data between March and July 2019. The content validation of the PSP was done by mental health and forensic experts (n = 7).

Expert interview

An interviewer’s guide to facilitate individual expert interview was developed for the study (available from authors on request). Face to face interviews were conducted in English by the first author. Notes were maintained during the interviews with CTPs, as audio recording was not permitted. The duration of each interview ranged between 45 min and 75 min.

Phase I process I: Development of the PSP

The interviews were transcribed manually, and each response was coded into themes and subthemes. The first two authors coded subsets of the interviews—thus, each interview was coded by two investigators independently and discussed with the third author for further review and investigator triangulation. The investigators reviewed the quotes and codes independently to reduce bias. Circular questioning was used to generate maximum responses from the experts. An interim coding of the themes and subthemes was conducted after every two interviews, and individual interviews were conducted till no new themes emerged out of consecutive interviews and qualitative data saturation was reached.[7] The qualitative data were subjected to thematic analysis, and the results were used to draft the PSP using a deductive approach.[8]

Phase I process II: Validation of the PSP

The draft PSP was validated for Face and Content Validity among experts who were selected using snowball sampling, and data were collected through an iterative process. For validation, the participants were required to assess each theme and subthemes as essential, useful but not essential, and not essential based on the content validity ratio (CVR), and in discussion with AJ and KPM, components were retained or removed.

RESULTS

Intervention development: Expert interviews, themes, and subthemes generation

A total of 6 MHPs, forensic psychiatrist, forensic psychologist, psychiatric social worker, and social worker and 2 CTPs, were interviewed. The mean age of the MHP was 38.11 (SD 6.6), with equal gender distribution in the sample. The mean years of education of the MHP were 19.0 (SD 7.0) and had a mean of 16.8 (SD 7.6) years of clinical experience. The mean age of CTPs was 36.24 (SD 3.4). A total of 10 themes and 26 subthemes were generated after the expert interviews with the experts. The major themes and subthemes elicited were depicted in Table 1.

Table 1

Development and feasibility testing of the peer support programme for prisoners with Common Mental Disorders (CMD) and substance use (SU): In-depth interviews with Mental Health Professionals, and Forensic Experts (Collated themes and subthemes)

FE: Forensic Expert, PSW: Psychiatric Social Worker, CP: Clinical Psychologist, CTP: Convicted prisoners, LE: Legal Expert MHP: Mental Health Professional
Themes/factors	Subtheme/subfactors	Quotes/Description
1. Mental health gap in prison settings	System related factors:  Lack of MH Services in Prison  Lack of MHP in prison  Lack of psychosocial services in the prison	“Various mental disorders such as depression and anxieties relate (ed each other in prison). In addition, nearly 80% have some forms of substance abuse, but since it is a prison set up, there are many challenges faced to address those issues" (MHP).
		“We found that most of the interventions were not psychosocial. Majority of it was (just) pharmacological treatment, the number of mental health professionals in the prisons was very less"(CP).
	Clinical:  The large magnitude of MH problems  Wide range of Mental health conditions	“See the substance use and common mental disorder in that (prevalence study, 2011) study what it had shown in the study that when they entered prison, it was less as in when they were staying there it has increased. duration of stay and prevalence increased, that is a hazardous phenomenon" (FE)
2. Factors contributing to mental disorders among the prisoners	Environmental factors:  Physical and mental abuse from fellow prisoners  Poor cleanliness and hygiene in the Barracks  Overcrowding living conditions in Barracks	“They have needs in terms of Psychological. No one is there to share their feelings and concerns. Uncertainty of what will happen after releasing from the prison. Concerns related to social acceptance. Even the solitary life in prison would itself lead to many issues” (CP). “I think the major thing (concern) is (overcrowding) crowdedness, lack of human resource, then lack of training itself.” (CP)
	Individual factors:  Negative emotion due to incarceration: Sense of helplessness, Sense of loss of social support  Abandonment by family  Challenges in adjusting to the loss of freedom  Preexisting Mental Illness	They (Prisoners) may not be able to meet their family members very frequently. These all are some of the situations that contribute to their poor mental health of the prisoners, sometimes they would enter with mental illness, and in prison, no one would be there to address those needs (PSW)
	System factors: (Painfully) the slow process of a judicial trial	“My strongest recommendation is to do speedy processing of undertrials. Do not procrastinate their trials. that can reduce many issues in the prison lot of issues they face like adjustment issues" (LE).”
3. Opportunities and prospects in the existing MH services in prison.	Service provided by Peers Service provided by the Mental Health Professionals Services provided by the volunteers and NGOs	“I have been here past two and half years.initially I was in the hospital side (medical hospital of the prison) and then came here…I have to supervise their ward activity.I have to remind them for the bath.sometimes forcefully taking them for a bath.most of them required that services.I have to manage their files by arranging in each day basis. then take them (prisoners) for follow up on a particular day…sometimes for other investigations such as blood test and urine test…”(CTP 1)
4. Need for peer support programme.	Capacity building by training the peer prisoner	“Many of the prisoners the number of available mental health professionals are far below the normal requirement that can be managed by training the staff and some of the convicted prisoners” (CP)
	Types of Peer Model:  Peer educator  Peer support  Peer Listener	“Such as basic counseling skills, then stress management skills, including listening, support, ventilation, identifying the person with mental illness. Those who require specialized care connecting them with treating” (FE)
5.Rehabilitation services in prison	Barriers to utilizing rehabilitation services	"See, the available rehabilitation sections are for all the prisoner’s rehabilitation…there is no separate rehabilitation sections or services for the prisoners with mental illness??…they utilize the existing service. But it doesn’t happen at any time. Because they will be in the ward, and there should be someone to motivate them." (FE)
	Vocational training opportunities in the prison Gym, Library, Tailoring, Bakery, Carpentry, Leisure and recreation, Financial planning	"We have a bakery unit, carpentry unit, the gym is there, the library has all the books, tailoring unit and now they also teach them music, language training. But all these services are using by the convicted prisoners…" (CP)
6. Components of training	Teaching identification of cases	“The major aspect is the identification of the cases so that early interventions can be given. For that, they (peers) should be trained enough in early warning signs and symptoms.also providing moral support.improving their mental health. they can also help for follow up….ensure treatment for them…” (PSW)
	Training in counseling skills:  Active listening  Education about mental health conditions  Expressing empathy	“See they (peers) can be trained in some of the skills like listening skills, offering support, being kind and empathetic towards the people who suffer these condition…even allowing them to ventilate when they are in distress all these things can be (added in training)." (FE)
	Content of training  Education of the mental health condition  Information about rehabilitation opportunities  Information on existing mental health services  Factors contributing to MH problems  Early warning signs of mental illness  Long term rehabilitation and reintegration into the community	“the most important thing is early warning signs if it is DSH or suicide even for other condition….symptoms of these conditions” (PSW)  "Follow up worker…relapse prevention techniques. Motivation enhancement training….adding the basic components of motivational interviewing as they can utilize for those who are a trainee. If the required additional services, they can always ask you (researcher) or the prison mental health team.” (FE)
	Substance use related  Craving management using the 4 Ds  Motivational interviewing  Preparing a motivational grid/matrix  Observation of behavior and emotions  Checking about dysfunctional thoughts
	Managing DSH/Suicide  Identifying a mental health crisis  Suicide gatekeeping  Preparing a crisis plan	“one more important part of the training should be suicidal gatekeeping programs, warning signs for DSH, suicide such as Early warning signs….DSH and all its basically identification…debriefing, preventing the further harm., linking them with the team etc.” (FE)
	Teaching about different roles of peers  Peer support  Services for prisoners about to be released  Peer listener  Peer educator	“They (peers) can be the first source of information providers. they can educate them about the condition.make them more aware of their situation…distraction techniques. So they can educate these people” (PSW)
	Advantages with the involvement of peers  Peer ability to empathize, easier disclosure with peers, acceptance of peers	“I think peers are ideal role models.for them to understand and empathies what they are going through, also for substance use and other condition. The compassion they have….the ability to be aware of the trauma.re-victimizations…various psychological issues….like understanding about PTSD….The psychological process of these issues….life experience” (CP)
	Potential roles of peers  Follow up of identified cases  Helping in medication adherence  Link with other prison services  Helping new prisoners toadaptto the prison environment  Providing psychological first aid	“any condition they should get handhold support for those who require support… DSH, Suicidal attempts to…peers should not be judgmental. Primary responsibility is peer supporter, can give.they have to be very calm…what are the feelings and concerns bothering them.provide information about the available support.once the problem identified they can provide listening and mentoring service.they can be vigilant if it is sensitive problem like suicidal ideas…each peer should have a co peer for their support” (PSW)
	Other components  Anger management  Stress management  Positive mental health  Social skills training  Recreation and leisure  Crisis management  Paralegal services  Healthy lifestyle  Conflict management	“ Need for yoga, meditation for improving the mental health of the prisoners” (LE) “stress management, healthy lifestyle….sleep hygiene techniques….engaging in a constructive activity….yoga and gym services….attending the groups.” (PSW) “One is life skill model, anger management techniques…role of exercise and physical activities for the promotion of mental health…these are the some of the things you can look forward in the” (CP)
7. Modes of training	Workshop model Roleplays Case vignettes Audio, video method Interactive discussion Pamphlets and handouts	“one is you can also make some videos….or you can take it from some other source….regarding identification…different diagnosis…what they have to do….that will give them more practical experience…” (CP) “explain to them (peers) the real case scenarios; role plays by the participants"(CP)
8. Process of training	Place of training Operating protocols Ethics of training Duration of training Tools for training Qualities of potential recruits Members of the team Telemedicine services	“It is not a recommendation .it is mandatory that along with peers a psychiatrist or trained Psychiatric Social Worker, Psychologist has to confirm the diagnosis…others can just give lay information.it will be more for understanding.information and compassion by a colleague rather than focusing on diagnosis aspects…Also they can explain about sections available in prison…time they can go to those sections…other information related to mental health care…we have prison population are telling that there are some of these important activities are available…and what benefit they will get, i.e., the peer volunteers also need to think well”(CP) "Another thing is technology.using technology.that has been penetrated deep into our country. It is advantageous and essential in a setting like a prison. Basic counselling…Basic psychotherapy…it’s a revolution in bringing technology in a public set up like prison would give a huge benefit. need to think about it…establishing a tele wing use software…we can reach to anywhere.deliver the service…training can be given to a patient can directly (FE)
9.Practical difficulties in implementing the peer programme	Attrition of peer supporters Poor cognitive abilities Lack of empathy and motivation Challenges in reporting sensitive issues Risk of malingering in cases Language barriers Interference from existing work schedule of peers	“See the challenges means the motivation of the volunteers (peers)…drop out is something which I think one (of the) challenge…Second is the language. Tools (of assessment) should be in local languages” (FE) “But their motivation level needs to be checked…most of them are engaged in some or other work. So how many of them would come will be a challenge.” (FE)
10.Handling practical difficulties	We were discussing confidentiality and reporting of sensitive issues to authority in the Informed Consent Form. Develop SOP for reporting the sensitive issue Sensitizing the authority	“right from the beginning in the informed consent form, you have to mention the research. (The information collected) is only for research purpose, and information should be confidential, not going to use for any other purpose.on the other hand, any risk such as suicidality, Deliberate self-harm…the things which have to be reported should be reported. then (in those situations) you will be breaking the confidentiality”(CP)

Phase I (a) and II (a): Validation of PSP

The drafted PSP was assessed face and content validity by seven experts. Four of the validators were male and three were females, and had a mean age of 38.00 (4.69). Among the validators were forensic psychiatrists (N = 3), Psychiatric Social Workers (N = 2), Social Worker (N = 1), and Clinical Psychologist (N = 1). The average educational qualification of the experts was 20.86 (1.069) with 9.71 years (SD = 3.72) of mean experience. The components of PSP were retained or removed based on the CVR proposed by C.H Lawshe.[9] Based on the CVR formula, 85.7 was the cut off for removing or retaining the components. The items retained below the CVR score were justified after discussion with all the coauthors. The items removed after calculating the CVR were long-term rehabilitation and reintegration plans for prisoners and post-release and paralegal services for prisoners during the time of release.

The final components included in the content of the PSP are depicted in Table 2. All the validators expressed that workshops, role plays, case vignettes, using audio-visual aids, and pamphlets would be essential for training the peers.

Table 2

Summary of peer support programme

Peer support intervention for prisoners with CMD and SU
Content	Day	Duration
Pre Sessions: Rapport building + Informed consent + assessments	1	3 Hours
Information about Common mental disorders (CMD) and Substance use disorders (SUD), Training in Assessment Tools	2	4 Hours
Suicide Prevention and Counselling skills (Basic Counselling Skills)	3	4 Hours
Roles and Responsibilities of the Peer Supporter in Management of CMD SUD and Suicide (Discussion and Role Plays)	4	4 Hours
Summary of sessions + Feedback + Assessments	5	3 Hours

DISCUSSION

We have developed and validated a comprehensive peer support interventions for mental health issues and SUDs that can be tested for effectiveness in Indian prison settings. To our knowledge, this has been done for the first time in India. These were developed after a systematic review of literature, expert interviews, and rigorous content validation. Several interventions have shown promising results for mental health issues and SUDs amongst prisoners—Motivation Enhancement Therapy,[10] Seeking Safety Programme,[11] Cognitive Behavior Therapy, Interpersonal Therapy, Music Therapy,[12] and Acceptance and Commitment Therapy.[13] However, these interventions were delivered by MHPs or prison staff. There is a shortage of MHPs to cater to the large prison population in India.[14] Despite availability of interventions such as yoga and meditation therapy, art and music, and vocational rehabilitation in India, these may not be sufficient to cater to the needs. Therefore, a sustainable capacity building programme, built on the concept of peer-led self-management support groups, could be an effective solution to manage mental health concerns. The gazetted rules issued by the Government of India recommend training of motivated prisoners to become peer supporters.[15] Peer support interventions have been an established part of prison systems in many countries with great diversity in their approach.[1617] The approaches have included peer educators, peer listeners, peer mentors, and peer counselors.[18]

The type of peer approach elicited from the qualitative interviews included engagement of peers as peer supporters, peer listeners, and peer educators. A systematic review conducted has also reported that these approaches were helpful in prison settings to address various CMDs, SUDs, and suicide.[16] Education and raising awareness about CMD and SUD was one of the key themes in the expert interviews. Studies conducted on training lay health workers in the community have reported that educating about various mental health conditions and SUDs would enable them to manage the conditions effectively.[19]

Early identification and early intervention for mental health and SU disorders was considered as a key role of peer supporters by the participants. Since there is an increased risk of mental health issues during admission and early period of imprisonment, screening in prisons during admission would help identify and manage psychological distress.[20] There is a potential role for peer intervention during this period.

The themes that emerged for managing SUDs among the prisoners included training peers in brief motivational enhancement techniques. Brief motivational interventions have been reported to be proven effictive for decreasing SUDs among the prisoners.[21] Improving motivation may be useful to reduce severity of SUD, for harm reduction, managing craving, and reducing reoffence secondary to SUD in prison settings.[22]

One of the important roles of peers elicited from the expert interview was their role as gatekeepers for suicide and self-harm prevention. The positive impact of peer intervention in preventing suicide in prison settings has been reported from other countries.[2324] The peer listener model has been considered an effective model for addressing distress and negative ideas amongst prisoners.[25] Observing for warning signs and asking for suicidal thoughts was considered important by our participants. Both behavioral and cognitive changes can be useful for early identification of suicidality among prisoners.[26]

The developed PSP would run under the supervision of prison mental health team as well as medical officers in situations of shortage of MHPs. The roles of mental health team include appropriate selection of peers by observing them and obtaining feedback from the prison staff, provide training to become peer supporter, and a regular follow-up during the process. The PSP can be considered as an adjunct to proper psychiatric intervention in the prison. A close watch must be maintained by qualified professional so that any serious psychiatric illness may be detected at an early stage, to enable proper psychiatric intervention at the appropriate time. Further, the supervision also includes handling sensitive issues and handholding during the process of training and delivery of intervention. The medical officers also can be utilized to keep a close watch to the peer supporters so that minor psychiatric disorders may be recognized and dealt with by them and for major disorders; they may refer to the services of a psychiatrist/mental health professional.

Although we have reported the systematic development of the intervention, we need to test its feasibility and effectiveness in the field. There may be several practical challenges anticipated in the implementation of the peer support model such as motivation of participants, ethical issues in reporting sensitive issues in the prison, and managing the dynamics in prison.

CONCLUSION

This study describes the development of a comprehensive PSP to identify and provide support for prisoners with mental health, SUD, and suicidal ideations. The PSP needs to be examined for its feasibility and effectiveness in addressing mental health problems in prison settings.

Financial support and sponsorship

University Grant Commission, Junior Research Fellowship.

Conflicts of interest

There are no conflicts of interest.