A Qualitative Co-Production Study of a Solutions-Focused Approach to Understanding the Barriers and Facilitators to Engagement of Male Suicidal Prisoners in Psychological Therapy for Suicide Prevention.

INTRODUCTION: Psychological therapies are rarely available for UK suicidal prisoners. A pilot feasibility clinical trial of Cognitive Behavioural Suicide Prevention therapy showed that it was possible to deliver therapy offering the potential to improve outcomes for suicidal prisoners. However, there were challenges to engaging male prisoners in therapy as many experienced difficulties in accessing and talking about their emotions. Difficulty in talking about emotions is common amongst male prisoners, yet this is essential for successful engagement in a talking therapy. The current co-production study aimed to further understand the contextual influences that impact male prisoners' ability to engage with a psychological intervention focused on suicide prevention and to explore user-generated solutions. METHODS: Community-residing male ex-prisoners with past experience of suicidal thoughts or behaviour during imprisonment participated in individual qualitative interviews followed by a series of six focus groups. Due to COVID-19 restrictions in place at that time, recruitment and data collection were conducted by remote methods. Data were analysed according to the principles of reflexive thematic analysis. RESULTS: Fifteen individuals participated: twelve completed individual interviews, ten participated in the focus groups, with seven individuals participating in both. Three main themes were formed. 1. Negotiating prison personas and identities - Pressures to hide emotions, act tough, and distrust professionals. 2. Command and control in prison - Prison regimes impact on interpersonal relationships with staff and other prisoners to worsen suicide risk, with prisoner's healthcare needs often neglected. 3. Making therapy accessible and acceptable - Prisoners must be able to trust a compassionate therapist for engagement to be successful. CONCLUSION: This study epitomises the feasibility and value of meaningful co-production in research involving populations from marginalised groups such as ex-prisoners. Our results reveal how the combination of individual prisoner and prison institution socio-cultural contextual influences impact suicidal prisoners' engagement in psychotherapy. User-defined suggestions are provided to promote development of potential remedies. PATIENT OR PUBLIC CONTRIBUTION: Co-production was achieved by the leading role of a salaried peer-researcher co-investigator in liaison with members of our Suicide Risk and Safety Research Group (SSRG) comprised of Experts-by-Experience (EbEs). Co-decision making featured throughout all stages of the research, influencing the protocol design and interview schedule. The personal experience knowledge of the peer-researcher/co-investigator enabled targeted recruitment strategies and successful engagement of participants. Shared past experiences of prison life and language positively influenced rapport and engagement of participants during data collection, enabling attainment of rich data. Similarly, the peer researcher/co-investigator's unique personal experiential knowledge ensured a 'real-world' perspective to analysis and co-authorship of publications.