Mental health
Key findings
- The current research evidence suggests that rates of mental illness amongst those under probation supervision are high. Despite this, nationally, there is a low uptake of the Mental Health Treatment Requirement.
- Service users have been found to face a number of barriers in trying to access healthcare and achieving positive mental health outcomes.
- Evidence suggests many mental health conditions often go unrecognised or unrecorded by probation practitioners.
- Despite the apparent benefits of probation staff receiving training in identifying and supporting mental health, studies suggest such training is often lacking. This is especially important as staff attitudes can play a crucial role.
- Liaison and Diversion services have now been rolled out across England and Wales and seek to identify those with mental health concerns and divert them away from the criminal justice system. Positive service user views were reported in the evaluation of the trial scheme.
Background
The relationship between mental illness and offending is complex. However, it has been found that levels of mental illness among those involved in the criminal justice system are higher than in the general population. A 2012 study suggests that a substantial percentage of the probation population have a current or previous mental illness, as well as high levels of dual diagnosis with substance misuse.
Lord Bradley’s 2009 review of the experience of those with mental health and learning disabilities within the criminal justice system reported failures to adequately address these needs. Bradley highlighted the importance of the following:
- the need for early assessment and identification of mental illness
- continuity of care throughout a service user’s criminal justice journey
- joined up partnership, including timely information sharing.
After the 2014 follow-up review by the Centre for Mental Health, Bradley noted that while there had been significant progress towards achieving his recommendations, there was still work to be done to ensure service users were receiving correct and timely support.
Summary of the evidence
Mental Health Treatment Requirements
Despite evidence which shows that incidence of mental health problems are higher among those involved the criminal justice system than in the general population, there is a low uptake nationally of the Mental Health Treatment Requirement (MHTR). As of March 2020, these made up less than one per cent of all court orders. A number of challenges for the delivery of MHTRs have been identified including:
- lack of access to appropriate mental health services
- some mental health workers being reluctant to treat someone when this is attached to a court order
- the need for greater understanding of issues of service user consent and stigma attached to mental health treatment – some may be unwilling to acknowledge that they have mental health problems
- the need for continuous engagement between criminal justice agencies, health commissioners, and treatment providers on all issues of service user health in the community.
Clinical Commissioning Groups (CCGs) are responsible for healthcare in the community, with Mental Health Trusts (MHTs) being expected to provide health and social care services to those with mental health disorders. However, findings from a 2017 survey sent to all CCGs and MHTs in England revealed that, on the whole, services were not being specifically commissioned for those on probation. Some small improvements have been seen in recent years, with increases in the proportion of both CCGs and MHTs investing in healthcare for probation clients.
Enablers and barriers
A number of additional barriers have been identified relating to the potential difficulties which those in contact with probation may encounter when trying to access healthcare and optimise mental health outcomes. These include:
- poor past experience of accessing care and mistrust of healthcare staff
- low levels of literacy and health literacy
- a lack of appropriate provision for complex needs
- poor access to GPs
- negative social determinants of health such as unemployment, homelessness, poor-quality housing, and low levels of education.
Factors which could facilitate access include:
- healthcare staff having a caring, professional demeanour
- improving service user literacy and health literacy
- improving commissioning processes and provisions for complex needs
- services having appropriate opening hours and being in accessible locations
- providing health information in plain, accessible language
- GP registration schemes
- co-locating staff or services
- addressing the social determinants of health.
Identifying mental health needs
Identifying mental health needs during probation supervision can be challenging. The OASys (Offender Assessment System) tool is completed by the probation officer, and it is thus reliant upon their recognising that a client is experiencing mental health difficulties. However, research has suggested that many mental health conditions are not recognised and/or not recorded.
Staff skills, training and attitudes
There is some evidence that where staff receive specialised mental health training, improvements result in knowledge and attitudes, although in general, probation staff demonstrate positive attitudes towards mental illness prior to their training. Yet studies also reveal that training of this nature is far from universal, with many staff relying on other sources of knowledge to identify and work with mental illness including knowledge derived from their own experience or previous roles, or on-the-job learning. Some staff have also called for the creation of dedicated posts with smaller caseloads which deal exclusively with those cases where a service user has significant mental health needs. A number of studies have reported favourable outcomes where specialist mental health probation staff are in post.
Having the right characteristics and attitudes towards services users has also been identified as having a positive impact. Characteristics such as empathy, honesty, non-judgementalism, perseverance, reliability, care, and commitment have been repeatedly cited by service users as important. Trust was noted as especially significant for those with serious mental illness because they perceived past interactions with authorities as being coercive.
Ensuring a proportionate attitude and risk response for service users with mental health issues is also seen as important to facilitate fair treatment. A number of studies have reported that those with mental illness are often deemed to be of higher risk, even when this is not confirmed by risk assessments.
Transitioning from custody
Transitioning from the structured environment of incarceration can exacerbate mental health problems, with the first few days and weeks after release being a time of heightened risk of self-harm and suicide. The lack of continuity of care also remains problematic for many service users with mental health problems. Thresholds for receiving interventions and services are generally lower in prison than the community, leaving service users unable to access equivalent support. Where prisoners are released many miles from their home, it is difficult to establish links with local health services.
Liaison and diversion
The impact of contact with the criminal justice system can have a lasting impact on a service user’s mental health which continues far beyond the period of a sentence. This can include trauma from the prison experience, the stigma of a criminal record, and difficulties in gaining employment. Based on recommendations from the Bradley Report, liaison and diversion (L&D) services were developed in 2010, achieving full roll-out across England and Wales in 2020.
An evaluation of the trial scheme reported that service users viewed the L&D services positively and found them helpful at a challenging time. Four in ten relevant cases were referred for one or more mental health interventions, and seven in ten had details of their conditions communicated to the criminal justice system. However, while magistrates and judges indicated that L&D services could inform sentencing decisions – including which conditions to attach to a community sentence and the decision on whether to impose a custodial or community sentence – findings from the sites did not reflect this.
In our full round of probation inspections competed during 2018/2019, the service user was identified as having a disability relating to mental health in just over a third of inspected cases (36 per cent; n=3,308).
Findings from our earlier Quality and Impact inspections (2016/17) revealed that while emotional wellbeing was identified as a priority in almost four in ten cases (39 per cent; n=1,127), sufficient interventions were delivered in only half of these cases (49 per cent; n=431).
Bradley, K. (2009). The Bradley Report: Lord Bradley’s review of people with mental health problems or learning disabilities in the criminal justice system. London: Department of Health.
Brooker, C., Sirdifield, C., Ramsbothan, D. and Deeney, D. (2017). ‘NHS commissioning in probation in England – on a wing and a prayer’, Health and Social Care in the Community, 25(1), pp. 137-144.
Brooker, C., Sirdifield, C., Blizard, R., Denney, D. and Pluck, G. (2012). ‘Probation and mental illness’, The Journal of Forensic Psychiatry & Psychology, 23(4), pp. 522-537.
Disley, E., Taylor, C., Kruithof, K., Winpenny, E., Liddle, M., Sutherland, A., Lilford, R., Wright, S., McAteer, L. and Francis, V. (2016). Evaluation of the Offender Liaison and Diversion Trial Schemes. Cambridge: RAND Corporation.
Durcan, G., Saunders, A., Gadsby, B., and Hazard, A. (2014). The Bradley Report five years on. London: Centre for Mental Health.
Eno Louden, J., Manchak, S. M., Ricks, E. P. and Kennealy, P. J. (2018). ‘The role of stigma towards mental illness in probation officers’ perceptions of risk and case management decisions’, Criminal Justice and Behaviour, 45(5), pp. 573-588.
Sirdifield, C., Marples, R., Brooker, C., Denney, D., Siriwardena, A.N., Maxwell-Harrison, D., Strachan, S. and Connell, T. (2019). Probation Healthcare Commissioning Toolkit: a resource for commissioners and practitioners in health and criminal justice. Royal Holloway University of London and University of Lincoln.
Sirdifield, C and Owen, S. (2016). ‘Probation’s role in offender mental health’, International Journal of Prisoner Health, 12(3), pp. 185-199.
