Young people who offend and mental health : co-design 'Across the Line'

Abstract

The mental health needs of young people who offend have become more widely recognised and a priority for the government and health agencies. Young people who offend experience a range of complex difficulties and have significantly worse health and social outcomes than their mainstream counterparts that persist and often increase in severity through childhood and later life. A wealth of research has been undertaken that focuses on young people’s health and well-being in the secure estate (e.g. custody) however, there is less research exploring the mental health experiences of young people who offend in community forensic settings. There is growing acceptance of the potential value of co-designing services that recognise and address problems to improve the outcomes of this population group yet to date, this remains relatively unexplored. The aim of this research was to explore, using qualitative research methodologies, (1) how young people presenting to youth justice services describe and understand their own mental health and needs, and (2) how a novel research approach (Experience-Based Co-Design (EBCD)) could be applied to facilitate recognition and service developments for young people with mental health difficulties presenting in community forensic settings. A qualitative systematic review and meta-ethnography of the research literature on how young people in contact with the youth justice system (YJS) experience mental health problems was undertaken. Fourteen studies were included in the review which represented 278 study participants in total, aged between 13-39 years (to capture retrospective accounts of offending behaviour). Included studies were conducted across a range of countries with different legal jurisdictions (six in the USA, five in the UK, one in Sweden, one in the Netherlands and one in New Zealand). The review aimed to explore how young people who offend talk about and describe their experiences of mental health; their beliefs and perceptions about mental health and well-being; what it means to be susceptible to mental health problems; and the kinds of language they use to describe this. The key findings were that: (1) some young people lacked the ability to understand their own and others’ mental health difficulties; (2) some young people were able to reflect on their experiences, and in some cases, they were able to develop ways of coping with their adverse circumstances, and (3) some young people indicated what does and does not work in their experiences of professional support. This review identified that better understanding is needed about the ways in which young people develop and show resilience to adverse circumstances and how they perceive their own situation, in order to develop services that are more appropriate to their needs. The review also identified that developing innovative ways to include young people in research and practice must consider the communication difficulties that young people who offend often experience. The evidence from this review contributed to the development of the primary qualitative study in this thesis. This qualitative study was designed and undertaken using a modified experience-based co-design (EBCD) approach. EBCD is an approach to healthcare improvement that enables staff and service users to jointly co-design services. Central to the approach is the idea that experiences held by service users and ‘touchpoints’ (e.g. critical points or moments) in their journey through a service are integral to service improvement. Qualitative methods used within this EBCD approach included: observational fieldwork in four police custody suites (n=30 hours); in-depth interviews with staff in community forensic services (n=13) and an interview sub-study of researcher perspectives (n=7). Significant challenges experienced in the recruitment of young people who offend into this primary qualitative study required revising the research plan. This revised plan included adopting a modified approach in the development of young peoples’ touchpoints and the inclusion of a qualitative interview sub-study of researcher perspectives to critically reflect on the EBCD research process itself. The findings from this primary qualitative study have demonstrated: (1) some of the challenges of working in the police custody environment and pressures on the services to deal with mental health issues; (2) the difficulties of working in community forensic services with young people who offend and who often have complex and unmet needs (e.g. lack of staff training and support, lack of smooth pathways to mental health services and difficulties engaging with young people and families); (3) a modified approach to including the experiences (i.e. touchpoints) of young people who offend can be useful and is feasible in gathering their experiences of youth justice services; and (4) the shared experiences of challenges faced by research staff applying the EBCD approach in similar studies with similar population groups. Findings presented in this thesis have contributed knowledge to an existing small body of evidence about how young people who offend experience and understand their mental health and towards the feasibility of applying the EBCD approach in community forensic services with this population group. Specifically, the findings suggest: allowing greater youth participation through re-framing assumptions about how young people experience their own mental health; developing capacity in community forensic services to facilitate joint working; increasing flexibility in and between services to promote service developments; and further modifying EBCD for disadvantaged and/or vulnerable groups.