With You has been working with Cornwall Council to deliver drug and alcohol treatment requirements within the judicial system for more than nine years. In 2020 a unique opportunity to combine mental health treatment requirements (MHTRs) with drug rehabilitation requirements and alcohol treatment requirements was identified by NHS England, the mental health commissioner in NHS Cornwall and the Isles of Scilly, and Kim Hager, joint commissioning manager for the Cornwall Drugs Partnership. Kim commissioned With You to deliver this combined service – a first for a drug and alcohol treatment provider.
An MHTR aims to provide an alternative to short-term prison sentences for those directly affected by mental health issues which could contribute towards their offending behaviour. This new combined approach of commissioning one service gives those in the criminal justice system access to dual diagnosis. So for the first time, those struggling with poor mental health as well as drug and alcohol issues could receive personalised, blended support.
Dual diagnosis
‘Before we introduced MHTRs in Cornwall to support people in the judicial system with clear mental health needs, no one had been successfully able to implement a dual diagnosis approach,’ explains Kim Hager. ‘Not only might a person be at risk of short-term prison sentences, but they would also have to go to two separate services for mental health and drug and alcohol issues. The system was not dealing with the whole person or their true situation, which naturally had a ripple effect.
‘In Cornwall specifically, rurality can also have an impact on mental health and the ability to access help,’ she continues. ‘While on the outside it might seem to be all jam and clotted cream, blue sky and sandy beaches, the reality is sadly, starker. Cornwall has some of the most deprived areas in the UK, but also in Europe. A lack of employment and housing, and adverse childhoods put the county on a par with Bristol and Manchester rather than neighbouring Devon, for example.’
Cornwall’s long history of deprivation goes hand-in-hand with higher rates of drug and alcohol use and other complexities.
‘So, when the opportunity arose to implement combined MHTRs and drug and alcohol orders in Cornwall alongside With You, which already has extensive experience in supporting drug and alcohol issues, we were always clear that we didn’t want this to work is silos. It would certainly benefit those affected, the system and those who operate within it by reducing pressure on them and overarching costs. The approach has also had a positive impact on the individual in the system who may otherwise have experienced a very different outcome in the first instance or be at risk of reoffence. There was initially some scepticism from other agencies around combining the orders and how effective this would be. However, what’s now evident is that our steering group of police, probation, the bench, and the NHS can all see the benefit of this approach.’
Onward referrals
As part of a combined order, With You can support people with moderate anxiety, depression, and personality disorders, but not with serious mental illness (which is eligible for a secondary MHTR). In these situations, there would be an onward referral to an appropriate mental health service. During the assessment, the team will review individual circumstances and the ‘why’ behind every case, which often sees them take a trauma-informed approach and acknowledge the role that this might play in their daily life.
Taking a trauma-informed approach can help break down the stigma and fear around mental health and identify any link between this and people who struggle with drug or alcohol misuse. We have provided additional training to upskill our team to enable them to deal with lower-level mental health issues, working holistically with a personalised approach to see what motivates the individual.
We haven’t thrown the rule book out, but we don’t sit behind a desk in a meeting room if we are supporting someone who struggles with formality and authority. We get out and meet people where they are in their lives.
We’re in a strong position of offering combined community sentence treatment requirements (CSTRs) which includes MHTRs, so we have a unique perspective of knowing the right time to start the drug treatment or mental health treatment. For some people we support, it’s about teaching them to recognise when they’re struggling with daily life and teaching simple breathing techniques, mindfulness, or CBT. For others, it’s about harnessing the power of the outdoors and nature with activities such as sea swimming or coarse fishing. Our approach is holistic and adaptive to the individual’s needs.
Huge potential
It’s apparent – and concerning – that those engaging with us have never received support for mental health issues before. One of the stand-out learnings for us is the use of functional analysis tools which are an integral part of MHTRs, helping to identify the root of the problem before developing a personalised solution for the individual. The potential for this kind of solution is stratospheric, and at a basic level is something that’s been right under our noses for too long.
‘If we don’t deal with trauma and mental health, we are inevitably going to see future generations facing similar issues, finding drugs and alcohol as solutions,’ adds Kim. ‘Our data shows us how important it is to look at the individual – what they need and when – because everyone’s needs will differ.
‘Many service providers don’t realise the link between neurodivergent conditions such as Aspergers, ADHD, depression, and low-level offending, or recognise that these individuals are increasingly finding it more difficult to access pathways to basic support, such as health, housing, and benefits.’
Culture change
Mental health is everyone’s responsibility, and the biggest mistake support providers can make is to treat everyone who offends the same. With You has introduced training for all frontline workers – not just those working directly on MHTRs – to help them better understand the link between mental health and drug and alcohol misuse.
There is an urgent need to address neurodiversity and recognise the role it plays in why people offend. The experience of the last two years has shown us that if you create a 12-week person-focused plan for someone with anxiety and no neurodivergent issues, this same plan would likely fail someone who has anxiety and untreated ADHD who is self-medicating with alcohol.
All our workers are able to adapt their practice and delivery to individuals with neurodivergent conditions, so that they can engage effectively in their CSTRs. The combined MHTR and drug and alcohol orders are working because the individual is at the centre of their own journey.
Eve Potts is operations manager at With You
For more information about With You Cornwall and the MHTR service visit: www.wearewithyou.org.uk/services/cornwall-truro
