Redefining the clinical workspace

Joan Idowu on her experiences as an Assistant Psychologist in a newly developed service for offenders accessing mental health support as an alternative to a custodial sentence.

In 2003, the Criminal Justice Act introduced three types of Treatment Requirements: Mental Health Treatment Requirement (MHTR), Drug Rehabilitation Requirement (DRR) and Alcohol Treatment Requirement (ATR). The MHTR helps an offender to undergo mental health treatment as part of a community or suspended sentence (National Offender Management Service, 2020). In 2018, out of all the requirements commenced under community orders, only 0.4% were MHTRs.

The Bedfordshire MHTR service is part of the national Community Sentence Treatment Requirement (CSTR) programme, a partnership between the Ministry of Justice, NHS England, Public health England, Department of Health and Social Care and Her Majesty's Prison and Probation Service (HMPPS). The aim of this partnership is to reduce reoffending, improve the health and social outcomes of individuals that come in through the criminal justice system and increase the number CSTRs issued (National Offender Management Service, 2020). Despite the demand of this service, the use of treatment requirements as part of a community sentence remains low and has been declining over recent years (Manjunath et al., 2018). 

The Role of an Assistant Psychologist on the PMHTR 

As an AP for the Court Liaison and Diversion Service, my role was to undergo the delivery of the Primary Mental Health Treatment Requirement (PMHTR). The PMHTR is for people with low to medium level mental health needs that are assessed as being treatable in a primary care service, and whose offending behaviour may be positively impacted by psychological intervention in the community (Long, Dolley, & Hollin, 2018). As part of the court order clients are required to complete 12 one-to-one sessions, with me under the supervision of a qualified Clinical Psychologist.  

The PMTHR uses value-based interventions, problem-solving and behavioural activation strategies. The sessions are designed to provide guidance, positive coping strategies, support and essential tools to manage behaviour and emotions. At the first point of contact, a three-way meeting is carried out with client, probation and myself to establish risks, expectations and complete pre-intervention questionnaires. The tests give an indication of the level of stress, anxiety and depression that each individual is at. On completion of the 12 sessions, these questionnaires are completed once again and a comparison is made between pre-intervention and post-intervention scores. 

The most rewarding and fulfilling part of the role is seeing the significant improvement made through the intervention scores, and writing up each client's progress in a completion therapeutic letter that they receive at the end of the PMHTR. Even when there is no significant improvement in the scores, the letter highlights specific areas the clients may need additional support with working on.

Initially, I assumed 12 sessions was a very short period of time to complete significant work. However, I found myself deeply immersed in the work and was able to address a lot of the clients' needs in the given time. The clients under the mental health service can be unenthusiastic about the prospect and experience of receiving mental health treatment under a court order at first. Clients can often be disengaged, disconnected and non-compliant, but I learnt to set the foundation of the intervention around the treatment being client-led, where they are in control of how much they benefit from these sessions. Creating a care plan together that includes their goals and set targets, gives the client a sense of control over the treatment they are receiving and I have found that this works better for engagement levels and promotes positive therapeutic relationships. 

Cultural Diversity and Mental Health 

In my line of work, I have recognised that my culture and identity impact the way I interact with my team but also how I build therapeutic relationships. Culture and diversity can be defined as integrated patterns of learned beliefs and behaviours (Vaughn, 2019). Giddens (1993), describes culture as a set of values that members of a group hold, which include the norms that they follow and beliefs that they share. During my experience in clinical practice, I have seen that cultural diversity amongst clients have a range of implications on people's views on mental health, the way one seeks support, and nature of therapeutic relationships (Gopalkrishnan, 2018).

Being a black African woman, my culture provides a framework for my behavioural and affective norms. In understanding how culture influences thoughts and action when dealing with individuals from the BAME (Black, Asian and Minority Ethnic) community, I include these norms when creating formulations and cultural adapted treatment plan that guide the course of the 12 sessions. A clinician's ability to establish rapport with clients from different cultural backgrounds is important. Some cultural groups may vary in their exposure to and experience with mental health services (Andrade, 2017), therefore it is important to understand cultural barriers that may be present in relationship building between professionals and clients.  

Many theories and practices implemented into psychology have emerged from Western cultural traditions and come from a Western understanding of the human mind and behavioural responses (Vaughn, 2019). In working with different people I have increased my cultural awareness, which is the ability to be conscious of cultural similarities and differences (Kirmayer et al., 2016). Cultural groups show variation in the types of stressors experienced and the coping styles developed (Gopalkrishnan, 2018).

How did the service change during Covid-19? 

On 23 March, the UK went under lockdown and mental health worsened substantially as a result of the Covid-19 pandemic, by an average of 8.1% (Xu & Banks, 2020). The Coronavirus Act (2020), put into place temporary changes to the Mental Health Act in order to ensure the safety, care and treatment of vulnerable people whilst we faced new economic uncertainty.

Alongside many other service providers, I have been challenged to modify my practices in order to provide care and support to those with existing or new mental health needs. Necessary adjustments made include moving to phone and video consultations. Martin-pena et al. (2017) stated that threats cause psychosocial effects, including elevated emotional reactions, increased perception of vulnerability and reduced perceived control. The lockdown measures created high-risk environments with increased pandemic-related stressors and limiting access to protective resources and support systems (Bradbury-Jones & Isham, 2020).

Specifically, for the clients I work with, the measures amplified emotional distress levels and risk of harm to self as well as harm to others. With the service being restricted and the access to additional support being limited many of the clients were referred to the crisis team when struggling with suicidal thoughts. The crisis team is part of a strategy to reduce acute bed use, they help service users who are experiencing a crisis of sufficient severity (Johnson et al., 2018).

The pandemic redefined and continues to redefine, the way we work as health professionals in delivering treatment. The health and safety of our service users are still the focus of everything we do, and like most services, I have had to make myself familiar with technology as well as the remote delivery of treatment. In some ways, it has been more convenient by telephone consultations, as I have managed to build great rapport with my clients as we both struggle in getting our heads around new video conferencing. I have been pleasantly surprised with the level of engagement with the PMHTR and how many clients have found it easier opening up over the phone. The number of 'did not attend' absences has considerably reduced, from an average of six per month to an average of two. As a result of this, there has also been an increase in the number of sessions delivered each month, reaching its highest attendance rate this year at 33 mental health treatment requirement sessions delivered in one month. 

Nonetheless, there are some challenges that have come to light, such as the absence of visual cues, ethical concerns surrounding confidentiality issues with sessions being overheard or recorded and technical limitation. Technology does not always work and not all clients have access to video call facilities. Many of the clients I work with have said that they miss face-to-face sessions whilst others have found telephone/ video call contact more practical for them. I have enjoyed thinking of new and creative ways of engaging my clients and making the sessions as interactive as possible, in order to ensure that they still benefit. 

Conclusion

In pausing and reflecting on my experience as an AP and watching what I once defined as 'normal' clinical practice change into something completely different, I learnt how to make my intervention more flexible and adapt to the 'new normal'. However, what remains a central thread through this journey is an appreciation for the opportunity to engage with impactful, meaningful work with people in the community. The privilege of working for the NHS during this time has afforded me with the perspective on how moving forward, technology could redefine how we deliver the clinical intervention and build therapeutic relationships remotely. As we transition from seats to screen it is important we continue to appreciate the culture and diversity of clients that access the service by implementing these cultural variations into treatment.

Joan Idowu

Assistant Psychologist

East London NHS Foundation Trust

[email protected]

References

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Johnson, S., Lamb, D., Marston, L., Osborn, D., Mason, O., & Henderson, C. et al. (2018). Peer-supported self-management for people discharged from a mental health crisis team: a randomised controlled trial. The Lancet392(10145), 409-418. doi: 10.1016/s0140-6736(18)31470-3

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Long, C. G., Dolley, O., & Hollin, C. (2018). The use of the mental health treatment requirement (MHTR): clinical outcomes at one year of a collaboration. Journal of Criminal Psychology8(3), 215–233. doi: 10.1108/jcp-01-2018-0003

Martín-Peña, J., Andrés, A., Ramos-Villagrasa, P., & Escartín, J. (2016). Living under threat: psychosocial effects on victims of terrorism. Behavioral Sciences Of Terrorism And Political Aggression9(3), 191-207. doi: 10.1080/19434472.2016.1198412

Manjunath, A., Gillham, R., Samele, C. and Taylor, P., 2018. Serving a community sentence with a mental health treatment requirement: Offenders' perspectives. Criminal Behaviour and Mental Health, 28(6), pp.492-502.

National Offender Management Service. (2020). Mental Health Treatment Requirement[Ebook].

Vaughn, L. (2019). Psychology and culture: Thinking, feeling and behaving in a global context. Routledge.

Xu, X., & Banks, J. (2020). The mental health effects of the first two months of lockdown and social distancing during the Covid-19 pandemic in the UK. The Institute Of Fiscal Studies. doi: 10.1920/wp.ifs.2020.1620

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