A project in Manchester is cutting reoffending among mentally ill offenders by helping them engage with mental health and substance misuse services, reports Mithran Samuel
● Name of service: Manchester Offenders: Diversion Engagement Liaison service (Mo:Del).
● Client group: People over 16 with history of offending, current substance misuse and probable diagnosis of mental illness or personality disorder.
● Objectives: To reduce criminal activity, drug and alcohol use, improve mental and physical health and increase engagement with services.
● Number of service users: 700 a year
● Number of staff: 11 (full-time equivalent) including one social worker, one probation officer, four nurses and a consultant nurse.
● Outcomes: Reduced reoffending, drink and drug use and mental health problems.
Special report on social care in prisonsMental health issues should not be a catch-all exclusion from the criminal justice system or from facing the consequences of your behaviour. But the likelihood of people offending is much reduced with treatment.”
This comment from Matt Paterson (pictured above), clinical lead and consultant nurse at the Manchester Offenders: Diversion Engagement Liaison (MO:DEL) service, sums up the philosophy of mental health diversion.
The prospect of reduced criminal justice costs from diverting people into treatment led the coalition to commit to establishing a national system of diversion services by 2014. But with provision still patchy, it will be vital to learn from good practice.
Established by Greater Manchester West Mental Health NHS Foundation Trust in 2009 after a pilot, MO:DEL has reduced drug and drink use and mental health problems among clients.
Just 27% of its clients are reconvicted each year when their history would predict a rate of 67%.
Its client group is highly challenging. Besides mental health problems, offending and drug or alcohol abuse, 94% were unemployed and 21% homeless, according to a 2010 evaluation.
Paterson says they are excluded from care services, often because their needs do not fit individual service criteria. “You have someone who has mental health problems who doesn’t fit the criteria,” he says. “They are using substances but they are not using the right substances or enough. They are homeless and certain agencies will not work with homeless people – not all of them are registered with the GP.”
Reconnecting them with services is key to improving health and reducing offending.
Cognitive behavioural therapy
About half of MO:DEL clients are “case managed” by the team because their care is not being managed elsewhere. MO:DEL works with them for up to six months, providing psychological interventions such as cognitive behavioural therapy, and working intensively to re-engage them with relevant services.
Andy Bell, deputy chief executive of charity the Centre for Mental Health, says MO:DEL is “almost unique” among diversion schemes in providing intensive case management, rather than simply assessing people referred by the criminal justice system and referring them on to other services.
Working with such an excluded group requires a positive approach. While assessments identify issues including risks to self or others, offending behaviour and history, clients are also encouraged to identify what they want out of the service.
“Because they have a history of not engaging with services, they usually react positively to that,” says Paterson.
“You need to think creatively about how to engage with them,” says the team’s probation officer, Sue Casey. “Maybe you phone them a bit more than you would [with a probation case] – you have to be a bit more persistent.”
MO:DEL’s work does not stop the minute clients are referred on, says Paterson. “Once they are engaged with the service we will disengage but not before.”
Before diverting people towards services, Paterson and his team need to ensure that clients are signposted towards MO:DEL from police, probation and the courts.
MO:DEL provides training to criminal justice staff in identifying offenders with a mental health problem.
Paterson says the police have an “operational and strategic” commitment to diverting people away from the criminal justice system “at the earliest possible opportunity”, though the initial response to cases is dependent on individual officers.
Lower-level offenders are often referred to multi-agency diversion panels, which consider whether people should go before the courts or be diverted into treatment, based on reports drawn up by MO:DEL.
“If it’s a relatively minor offence we look at what options are available,” says Paterson. “We arrange for follow-up [with the client] and, provided that is in place, the police take no further action.”
In about 60% of cases, offenders do not go to court.
Where offences are more serious, offenders go before a “targeted services court”, a specialist court where magistrates are trained in mental health.
Ordinarily, the team has two weeks to prepare reports for the court. These include information on the services the client is in contact with and the support they receive.
Where someone is in touch with services, options could include discharging the offender on the condition that they maintain contact with their community psychiatric nurse, says Paterson.
He says the court usually agrees to the team’s recommendations.
Paterson is positive about the national priority given to diversion, but is concerned about the impact of cuts to care services.
“If we don’t have an effective system for ensuring that offenders with mental health problems have somewhere to go what’s going to happen to all the cases we are identifying?” he says.
Case studies: How MO:DEL changed the lives of two offenders
When Michelle* was released from a 16-month jail sentence for theft, she told prison staff she would “see them in four days”. Having no accommodation but feeling safe in a custodial setting, Michelle planned to commit further offences. She had received a diagnosis of schizophrenia while in prison and had a long history of suicide attempts.
After being referred to Mo:Del, the team worked to register her with a GP so that she could access mental health services. Mo:Del staff supported her to attend initial appointments with her psychiatrist, monitored her progress, and worked with the community mental health team to ensure a smooth transition into longer-term services.
The staff also helped Michelle claim benefits that were not previously in place, find suitable accommodation and attend housing appointments. She is now receiving services from the community mental health team, is in suitable accommodation and has not returned to prison.
Steve* says he had lost the will to live when he was directed to the Mo:Del team by a drug agency after committing an offence. He had a history of acquisitive and drug-related crime, for which he had served time in prison, used multiple substances and was socially isolated. He was not registered with a GP or receiving health services.
Mo:Del worked with him for six months. It used node-link mapping, which involves presenting information in a simple diagram, to help him recognise his problems and formulate realistic plans for solving them. It also supported him to register with a GP and access medical treatment.
“Today I am on antidepressants and I feel so much better mentally”, he says. He cites the importance of the approach taken by his Mo:Del case worker. “She listened to what I said, I knew she understood what I was going through.”
Steve says his physical well-being has gone from “very poor” to “good”, adding: “Mo:Del supported me and gave me hope.”
*Names have been changed
Picture by Neil O’Connor