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Evaluating a service for offenders with mental health problems

Individuals whose mental health problems bring them into contact with the criminal justice system should be diverted into appropriate health care services. Where this is not possible, they should receive appropriate mental health care within police custody and during the transition between court and prison, whether they are finally remanded or convicted. Apart from the obvious duty of psychiatric agencies to ensure that this service is provided, it is economical in financial and human terms for both the individual and the community in general to divert appropriate individuals from custody (Hillis, 1999).

Abstract

VOL: 99, ISSUE: 42, PAGE NO: 24

Vincent Baxter, MSc, BSc, RMN, is team leader in community forensic nursing, South Staffordshire Mentally Disordered Offenders Team, South Staffordshire Healthcare NHS Trust

 

Individuals whose mental health problems bring them into contact with the criminal justice system should be diverted into appropriate health care services. Where this is not possible, they should receive appropriate mental health care within police custody and during the transition between court and prison, whether they are finally remanded or convicted. Apart from the obvious duty of psychiatric agencies to ensure that this service is provided, it is economical in financial and human terms for both the individual and the community in general to divert appropriate individuals from custody (Hillis, 1999).

 

 

Background to the service
The past three decades have seen a succession of policies and reports advocating the diversion of those with mental health problems away from the criminal justice system and into the health care system (Department of Health and Home Office, 1992; Home Office, 1990). There are potentially many routes for diverting those with mental health problems into psychiatric care. However, the Mentally Disordered Offenders (MDO) team covers two of the main routes by providing a service at the point of arrest and a court liaison service.

 

 

Crime has both direct and indirect effects on health and its psychological and physical consequences can be long-term. Crime can also add to social inequality, reduce the effectiveness of health care systems, and create health burdens such as alcoholism and drug dependency. By engaging with those who come into contact with the criminal justice system as a result of mental health and associated problems, the MDO team can offer support, assistance and alternative ways for individuals to cope with their difficulties. The team is therefore able to help individuals break their cycle of offending, in turn helping to reduce levels of crime.

 

 

The MDO team
The South Staffordshire MDO team provides a range of services aimed at assisting and supporting individuals with mental health problems or needs who become involved in the criminal justice system. The team visits police custody sites and magistrates courts throughout South Staffordshire on a daily basis to screen for and identify individuals with mental health problems. The team provides help to the probation service, working with individuals both before and after sentencing. The team’s probation officer provides pre-sentence reports, which can offer alternatives to custody such as referral to an appropriate agency or treatment programme.

 

 

The team also works with convicted individuals, assessing their needs and supporting them and their supervising probation officer, and accepts referrals from GPs, community mental health teams and social services, and will either support those referred for a short period or refer them on to appropriate agencies.

 

 

The MDO team includes: community forensic nurses, an approved social worker, a probation officer and access to the services of a clinical psychologist and consultant forensic psychiatrist. The team often engages with individuals who have either lost contact with various services, or find it difficult to access help.

 

 

By identifying and working with these individuals the team is able to assist them in beginning to address their problems and/or needs. This can often relieve the tremendous distress they experience, and provide them with hope for the future. In many cases the team can also help individuals to address issues that contribute to their offending behaviour, and thus assist them in breaking the cycle of behaviour that brings them into contact with the criminal justice system.

 

 

Research has shown that offenders with mental health problems are more likely to be remanded in custody and receive longer sentences than those with no mental disorder (Cavadino, 1999; Kennedy et al, 1997). Individuals in this group are commonly homeless, guilty of non-serious offenses, and have been given an indeterminate psychiatric diagnosis. They may also pose an insufficient risk of ‘dangerousness’ to justify the costly and damaging aspects of them being remanded in custody. By identifying and addressing the needs of these individuals, the MDO team is able to combat some of the discrimination they face and promote their social inclusion.

 

 

Through the provision of timely and proactive intervention the team is able to ensure individuals with mental health and associated problems gain access to a service that will assess and identify their needs and offer them effective treatments. The team also refers individuals to specialist services for further assessment, treatment and care as required.

 

 

By providing a comprehensive assessment of individuals the team is able to determine their current mental state, gain a broad picture of their problems and/or needs, and assist in the management of those at risk of self-harm or suicide. This enables these individuals to be safely managed during their time in custody, and forms the beginnings of a risk management and treatment plan for them on their return to the community. This contributes to the delivery of the National Service Framework for Mental Health (Department of Health, 1999).

 

 

Assessment tools
Two assessment tools are used by the team. The assessment carried out in police and court custody involves a brief mental health screening. This covers past psychiatric history, current state of mental health, offending history, risk to self and/or others, drug and alcohol use, and the ability to cope in custody. Assessment is usually carried out by one member of the team who attends these venues on a daily basis, or is available on-call. Assessments are undertaken at the request of staff, although the team reviews prisoner escort records in an attempt to identify individuals for assessment. The aim of the assessment is to advise police and court custody staff on issues of safe custody, provide advice to the court and police that may be helpful in dealing with the individual concerned, and to identify individuals who may require in-depth assessment.

 

 

An in-depth assessment is necessary for clients referred from elsewhere. This includes details of: the presenting problem, social circumstances, family and personal history including significant life events, past psychiatric and medical history, drug and alcohol use (past and present), forensic history, current state of mental health, social supports, and risk to self and/or others. The assessment is usually undertaken by two team members, preferably from different disciplines.

 

 

Assessments are usually carried out by appointment at health, probation or social services premises. The aims of assessment are: to contribute to the pre-sentence report, to obtain an overview of the client’s circumstances, to help plan the best way forward for the client, to aid in referral to other services or agencies, and to identify issues for further investigation or areas where the team feels it is able to provide support or assistance.

 

 

The evidence
There is a wealth of evidence demonstrating the beneficial effects of diverting those with mental health problems away from the criminal justice system. Where liaison schemes are in operation at magistrates’ courts they have been shown to considerably reduce the number of days individuals are remanded in custody for psychiatric reports (James and Hamilton, 1991).

 

 

Follow-up studies of individuals admitted to hospital as a result of court liaison schemes have found that significant numbers have benefited from psychiatric treatment (Holloway and Shaw, 1993).

 

 

Studies examining the work of diversion-at-point-of-arrest schemes have shown that they have identified large numbers of individuals with significant mental health problems (Riordan et al, 2000). Such schemes have also been shown to have diverted significant numbers of those arrested by the police into hospital, either formally under the Mental Health Act (1983) or through voluntary admissions (James, 2000).

 

 

The survey
A survey was undertaken to evaluate the work of the MDO team. This involved sending out two separate questionnaires to referrers to the service and to its users. The number of completed questionnaires received was very disappointing, despite repeating the process in each case:

 

 

- Referrers - 11 out of 57 (19.30 per cent);

 

 

- Clients - 8 out of 51 (15.69 per cent).

 

 

Using a questionnaire to collect data may account for the disappointing response rate, according to Parahoo (1997). The small sample therefore limits the significance of the survey results.

 

 

Summary of results
The results from the referrers’ survey were very encouraging (Box 1, p25). The only area where it was felt there could be an improvement was in the form used for referring patients to the MDO team.

 

 

The results from the clients’ survey were not quite as good (Box 2). The main problem highlighted seemed to be a lack of knowledge and understanding regarding the MDO team’s activities. The MDO team was already aware of this issue and had decided to send an information booklet with the clients’ appointment letters. Unfortunately, by this time many of the clients had already been interviewed.

 

 

Recommendations
The following were made for improving the service:

 

 

- Standard time for replies and feedback to referrers;

 

 

- Extra sheet required on assessment sheet with tear-off summary of future actions points;

 

 

- Client feedback sheet;

 

 

- Review referral form;

 

 

- Information booklet to be included with clients’ appointment letters.

 

 

Action to be taken
An action plan was drawn up from the recommendations for improvement:

 

 

- To incorporate a standard time for verbal and written feedback to referrers within the team’s operational guidelines, and to audit this on a regular basis to ensure targets are being met;

 

 

- To add an additional sheet to the team’s assessment forms, where a summary of the assessment and actions to be taken forward with the client’s agreement will be written. A copy will be given to the client;

 

 

- To review and make any necessary changes to the team’s referral form;

 

 

- To proceed with the inclusion of the information booklet with clients’ appointment letters;

 

 

- To re-audit in 12 months time in order to determine if the above actions have increased levels of satisfaction among clients and referrers.

 

 

Dissemination
The team has disseminated its work in various ways. A half-day forum was held and information was displayed at the South Staffordshire Health Care NHS Trust’s annual general meeting.

 

 

Visits have also been arranged for other teams and professionals through the trust clinical governance report, presentations at conferences, and presentations to partner agencies and key stakeholders.

 

 

Conclusion
The South Staffordshire MDO team is a truly multidisciplinary team/agency. It offers a service that can assist in removing the distress that those with mental health problems can experience when they come into contact with the criminal justice system. This is done by offering timely intervention and access to appropriate services and therapy.

 

 

The service also offers the potential to relieve the criminal justice system of the pressures associated with attempting to care for individuals with mental health problems within a system that is likely to reinforce aspects of mental disorder and exacerbate young offenders existing conditions.

 

 

- This article has been double-blind peer-reviewed.

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