The use of the mental health treatment requirement (MHTR): clinical outcomes at one year of a collaboration
| Date | 06 August 2018 |
| DOI | https://doi.org/10.1108/JCP-01-2018-0003 |
| Published date | 06 August 2018 |
| Pages | 215-233 |
| Author | Clive G. Long,Olga Dolley,Clive Hollin |
| Subject Matter | Health & social care,Criminology & forensic psychology,Criminal psychology,Sociology,Sociology of crime & law,Deviant behaviour,Public policy & environmental management,Policing,Criminal justice |
The use of the mental health treatment
requirement (MHTR): clinical outcomes
at one year of a collaboration
Clive G. Long, Olga Dolley and Clive Hollin
Abstract
Purpose –In the UK, the mental health treatment requirement (MHTR) order for offenders on probation has
been underused. A MHTR service was established to assess the effectiveness of a partnership between a
probation service, a link worker charity and an independent mental healthcare provider. Short-term
structured cognitive behavioural interventions were delivered by psychology graduates with relevant work
experience and training. Training for the judiciary on the MHTR and the new service led to a significant
increase in the use of MHTR orders. The paper aims to discuss these issues.
Design/methodology/approach –A total of 56 (of 76 MHTR offenders) completed treatment in the first
12 months. A single cohort pre-post follow-up design was used to evaluate change in the following domains:
mental health and wellbeing; coping skills; social adjustment; and criminal justice outcomes. Mental health
treatment interventions were delivered under supervision by two psychology graduates who had relevant
work experience and who were trained in short term, structured, cognitive behavioural (CBT) interventions.
Findings –Clinically significant changes were obtained on measures of anxiety and depression, and on
measures of social problem solving, emotional regulation and self-efficacy. Ratings of work and social
adjustment and pre-post ratings of dynamic criminogenic risk factors also improved. This new initiative has
addressed the moral argument for equality of access to mental health services for offenders given a
community order.
Originality/value –While the current initiative represents one of a number of models designed to increase
the collaboration between the criminal justice and the mental health systems, this is the first within the UK to
deliver a therapeutic response at the point of sentencing for offenders with mental health problems.
The significant increase in the provision of MHTR community orders in the first year of the project has been
associated with a decrease in the number of psychiatric reports requested that are time consuming and do
not lead to a rapid treatment.
Keywords Social care, Mental health, Offenders, Probation, Cost of crime, Risk of re-offending
Paper type Research paper
Introduction
Mental health tre atment within comm unity settings has , in the era of de-inst itutionalisatio n,
targeted vulnera ble groups includin g those with and without a cr iminal offending his tory.
Over the past four decades, the Community Treatment Order (CTO) has been a preferred
clinical and policy solution for addressing non-adherence to treatment on the part of patients
with severe mental illness in 75 jurisdictions worldwide (Rugkasa, 2016). CTOs are used, in the
main, for patients with schizophren ia, a history of non-adherence to treatment, a concurrent
substance misuse problem and a history of violent or criminal offences (Rugkasa, 2016).
Likewise the chall enge of the nature and prevalence o f mental illness among criminal o ffenders
in the UK, England an d internationally has led to se rvices designed to meet the comp lex needs
of mentally disordered offenders. In the USA, these include drug or mental health courts
(MHCs) while in the UK C riminal Justice Lia ison and Diversion ( CJLD) services have b een
developed at courts or in police stations (Scott et al., 2016). To date however, randomised
Received 16 January 2018
Revised 9 February 2018
Accepted 9 February 2018
Clive G. Long is the Consultant
Psychologist at the Albion
Consultancy and Treatment,
Northampton, UK.
Olga Dolley is Trainee Clinical/
Forensic Psychologist at the
St Andrew’s Healthcare,
Northampton, UK.
Clive Hollin is the Emeritus
Professor at the Department of
Psychology, University of
Leicester, Leicester, UK.
DOI 10.1108/JCP-01-2018-0003 VOL. 8 NO. 3 2018, pp. 215-233, © Emerald Publishing Limited, ISSN 2009-3829
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controlled trials (RCTs) of CTO s have failed to show tha t they have any signi ficant effect on
the treatment outc ome of patients (Rugka sa, 2016; Burns et al., 2013). The evidence for the
effectiveness of CJLD services in UK and USA is also mixed (Parkes and Winstone, 2010; Scott
et al., 2016).
In the light of these fin dings, it has been sug gested that the futur e development of CJLD
services in the UK sho uld examine the use of “conditionality”in criminal charging with courts
being more proactiv e in the use of options such as the comm unity order which is served under
the supervision of p robation staff as a rob ust alternative to s hort-term custodia l sentences
(Scott et al., 2016). The option of inc orporating mental health as part of a c ommunity sentence
was originally introduced as a psychiatric treatment condition (Criminal Justice Act 1948).
This was subsequentl y replaced by the Community Rehabil itation Order with a requirement for
psychiatric treatment in 2001 and with the current mental health treatment requirement (MHTR)
in 2005. Those subje ct to a MHTR are required to r eceive treatment b y or under either a
registered medical practitioner or registered psychologist for a specified period. The offender
must be willing to comp ly with the order and app ropriate treatme nt must be available.
The MHTR is one of 12 com munity orders that ar e designed to addre ss the offender’s
criminogenic needs that are linked to the perceived risk of offending. However there has been
an under-use of MHTR orders (Khanom et al., 2009) such that it constitutes less than 1 per cent
of requirements made as part of community orders and evidence of their effectiveness is
lacking (Scott and Moffat, 2012).
There is a paucity on research on the prevalence of mental illness in those presenting in courts
(Bradley, 2009) and in offenders on probation in the UK (Sirdifield, 2012). However a prevalence
study by Brooker et al. (2012) in one probation trust in England found that 39 per cent of
offenders are likely to experience a mental illness whilst on probation with half of that population
having a past or lifetime disorder. In addition there was a high prevalence of co-morbidity
(a mental illness and a personality disorder) and of dual diagnosis (a mental illness and substance
misuse). The most common group of disorders are those related to anxiety (27 per cent) and to
mood disorders such as depression (18 per cent). These findings echoed those of one of the
most comprehensive US studies of the mental health of people on probation (Lurigio et al., 2003).
Findings in the prison population attest to the complexity of clinical presentations among those
with the co-occurrence of mental illness with substance abuse and personality disorder (Sirdifield
et al., 2009). This combination of mental health problems and/or personality disorder and
substance use disorder has a detrimental impact on treatment (DiClemente et al., 2008) and is
characterised by a lack of engagements with therapy, poor motivation and relapse.
Offenders with serious mental illness are twice as likely to fail in community supervision
(Skeem and Louden, 2006). In a study of an unmatched USA sample of 613 probationers
followed for three years, Dauphinot (1996) found that probationers with mental illness were
significantly more likely to have probation revoked that those without (37 per cent compared with
24 per cent). Such offenders are frequently failed by services that are not geared towards the
needs of this population (Skeem and Louden, 2006). Their needs are deemed too complex by
mainstream community care services (Vaughan and Stevenson, 2002) and, like other criminal
justice institutions, the probation service was not designed to meet the unique challenge of
individuals with mental illness (Skeem et al., 2006).
A further issue is that offenders on probation find it difficult to engage for reasons that include
concern around stigmatisation, disenchantment with mental health services (Vaughan and
Stevenson, 2002) and problems in forming a therapeutic relationship that are reflective of
personality disorder (Barnicot et al., 2011) and chaotic lifestyles that reflect social care needs.
In addition their problems of co-morbidity make access to mainstream services such as
Improving Access to Psychological Therapies (IAPT) problematic (Richards and Borglin, 2011).
A number of initiatives have attempted to address the needs of offenders with mental health
needs on probation. In the USA, a growing body of literature suggests that speciality agencies
(where offenders with mental illness are assigned to probation officers with some mental health
training and relatively small caseloads) hold promise for improving clinical and criminal outcomes
for probationers with mental illness (Skeem and Louden, 2006). In the UK, the employment
of mental health workers by the probation service has shown promise (Cohen et al., 1999).
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