Research & reports

Introduction

The probation service in England and Wales has been subject to significant reforms and changes since its creation in the early part of the 20th century. A recent reform that has affected its structure and practice has been the 2003 Criminal Justice Act which gave Magistrates requirements from which to choose when making up community orders. Such requirements are selected on the basis of their potential to reduce the future risk of reoffending by targeting criminogenic needs. The Mental Health Treatment Requirement (MHTR) is one of 12 such requirements that can be recommended when:

The offender does not have a condition requiring a hospital or guardianship order but has a condition that requires and is susceptible to treatment

However, there has been infrequent and under-use of the requirement, with recent evidence of a decline from 809 MHTRs in 2009 to 656 in 2011 (Scott and Moffatt, 2012), representing less than 1 per cent of all requirements made as part of community orders. This situation is surprising given the number of offenders carrying out a community sentence who have mental health problems; recent estimates suggest that 39 per cent of offenders supervised by probation services have a mental health problem (mostly anxiety and depression) and that the majority of these also have a substance misuse problem (Brooker et al., 2012). Given that 306 offenders were supervised by the probation service in a 12-month period (March 2012–March 2013), it is likely that up to 89,000 experienced mental health problems on probation and that many would have benefitted from a MHTR. While the relationship between mental health problems and offending is poorly understood (Peay, 2011), it is claimed that ‘wider use of the MHTR could result in improved health outcomes and reduce reoffending, cutting the costs of crime for the community’ (Scott and Moffatt, 2012: 2).

There are clear reasons for the underuse of MHTR (Khanom et al., 2009; Scott and Moffatt, 2012) that include:

Uncertainty about the eligibility criteria among criminal justice staff

Lack of access to services for offenders with mental health problems is a known difficulty, with perceived or lived stigma adversely affecting engagement. Many people in contact with the criminal justice system do not have their mental health problems adequately identified in a timely manner. Thus, if an assessment is not arranged and conducted, a MHTR cannot be issued. Even if an assessment is arranged, it may not be possible to access services unless the assessor has connections with local service providers who themselves often have built in restrictive criteria and long waiting lists. Sentencers should require and expect the identification and assessment of defendants with particular support needs in order that appropriate action can be taken during court proceedings. For some offenders this might mean diversion away from the criminal justice system and into appropriate easily accessible healthcare.

However the major obstacles to the use of the MHTR are the (non) existence of appropriate treatment arrangements that can be accessed in a timely manner. Despite more than 50 years of research into, and development of, effective cognitive behavioural treatments for depression and anxiety, healthcare providers are unable to deliver recommended treatments. In the UK, for example, no more than 10 per cent of people with anxiety and depression receive psychological treatments for their problems, and only 5 per cent had access to an evidence-based psychological treatment (McManus et al., 2009). Offenders with mental health difficulties receiving community supervision are frequently failed by services that are not geared towards the needs of this population (Skeem and Louden, 2006). In addition, offenders find it difficult to engage. The need to overcome such barriers and make more effective use of the MHTR is based on both moral/equal access to mental health facilities and economic and social (costs of custody) grounds. Recent innovations designed to increase access to evidence-based cognitive behavioural treatment (Improving Access to Psychological Therapies: IAPT) do not cater for those with substance misuse, and only half of those referred go on to receive treatment (Richards and Borglin, 2011). This represents a significant barrier to the dual diagnosis population of offenders who have problems of engagement and who could potentially benefit from mental health services (Brooker et al., 2012).

To address this issue a demonstrator project initiative was established in April 2014 to evaluate the effectiveness of an integrated mental health and criminal justice initiative. This project is a joint venture between Thames Valley Probation Service, the charity People Potential Possibilities (P3), which provides social, educational, vocational and practical support for offenders, and St Andrew’s Healthcare (a charitable trust and independent provider of mental health care).

The project

An enhanced offender journey

An enhanced offender pathway has developed to include the rapid response assessment and treatment of mental health problems.

In the current system offenders supervised by probation services may also receive P3 input and/or help with mental health problems (St Andrew’s). Referrals, the majority based on cases opened by probation officers, can be made to the P3 Probation Court Link Worker Service, who offer a home visit and assess the need for interventions that include housing, finance and benefit, relationships, substance misuse, attitudes and behaviour.

An initial assessment is completed at court by P3 and probation officers who produce a response for the judiciary to help determine the best sentencing option. In the new working model the P3 assessments include the administration of a screening tool to assess for mental health problems (the Kessler 10 [Kessler et al., 2002]), a measure of psychological distress). Offenders scoring above the cut-off for a clinically significant level of distress are then assessed by St Andrew’s staff, using interview and further psychometric baseline measures in order to provide the psychological report required to support a MHTR recommendation. Such assessments will make recommendations regarding the psychological treatment interventions and/or the need for psychiatric screening, psychotropic medication or onward referral to the community mental health service. This enhanced offender journey is described in Figure 1.

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Figure 1.

Probation service offender management.

In an integrated service, offenders supervised by probation can receive link worker input from P3 alone or from St Andrew’s Healthcare and P3. All three services are co-located in the probation service offices.

Psychological intervention service

Within the demonstrator site model the delivery of a psychological assessment and treatment service is undertaken by assistant psychologists following training in psychometric test administration and the delivery of individualized treatment interventions. Assistant psychologists based within the probation service building are supervised by qualified psychologists working in forensic psychiatric settings.

Assessment of the offender’s mental health issues uses a semi-structured interview that is both motivational and fact finding. The interview captures a range of data including mental health and forensic history, current involvement in treatment, use of medication, and life problems. Psychometric assessments screen for personality disorder (using the Standardized Assessment of Personality – Abbreviated Scale: SAPS [Pluck et al., 2012]), depression (Patient Health Questionnaire: PHQ9 [Kroenke and Spitzer, 2002]), anxiety (Generalized Anxiety Disorder 7: GAD7 [Spitzer et al., 2006 ]), self-efficacy (Generalized Self Efficacy Scale: GSES [Jerusalem and Schwarzer, 1992]) and social adjustment (Work and Social Adjustment Scale: WSAS [Mundt et al., 2002]). Interviews and psychometric test data determine the appropriate psychological interventions, which may include a recommendation regarding assessment for medication or psychiatric screening.

Treatment interventions delivered have been dictated by the following considerations:

The nature of the offending client whose mental health problems encompass in the main personality disorder, depression and anxiety (Brooker et al., 2012)

Following assessment, decisions are made about the type and duration of treatment. The treatment intervention offered is structured, short-term skills training to promote behaviour change. It is an adapted version of dialectical behaviour therapy (Linehan, 1993) skills for borderline personality disorder. Training accordingly focuses on managing emotions and social problem-solving (interpersonal effectiveness). Individual treatment is adapted from treatment manuals developed and evaluated for patients with mental health problems and offending histories:

(i) Dealing with Feelings (Long et al., 2011)

Sessions cover distress tolerance, emotional regulation and reducing emotional vulnerability. Individuals also develop individual relapse prevention plans based on what they have found helpful

(ii) Social Problem Solving (Long et al., 2011)

This treatment is adapted from the five step problem-solving training manual (Nezu et al., 2007) and from the ‘Stop and Think’ problem-solving therapy for personality disordered offenders (McMurran et al., 2005).

Clients are offered up to 12 sessions of either ‘Dealing with Feelings’ or ‘Social Problem Solving’ or, in some instances, both therapies.

Staff training and development

Assistant psychologists were recruited who had a good upper second class or better psychology degree and previous relevant experience in delivering treatment under supervision in community or forensic settings. Having well-trained staff to carry out treatment or plan is a management issue (Hollin, 1995). Three levels of training were identified: awareness training of the client group, probation and related services; core knowledge and skills for CBT; and manual-specific training. Ongoing supervision of case work was undertaken by a trained forensic and clinical psychologist.

Treatment integrity

Treatment integrity is an integral part of achieving successful treatment outcomes: it covers therapeutic competency, treatment differentiation and, in particular, treatment adherence: the degree to which therapeutic procedures are implemented as intended (Perepletchikova and Kazdin, 2005). The agreed method of integrity audit and monitoring was unannounced random ‘sitting in’ on sessions (with client agreement) by supervising staff familiar with manual content. Specific recording sheets noted the extent of adherence to the treatment manual and session goals (Long at al., 2011).

Evaluation

The ultimate task of an intervention is its effectiveness in achieving targeted change (Milne and Paxton, 1998 ).

A service evaluation, independently undertaken, is ongoing. It assesses the following:

Use of MHTR provision

Further analysis will involve the identification of those who derived most benefit from the service.