The best of mental health

1 April 2011 6 mins read Tom De Castella Health Mental health

The recent mental health strategy identified The Brandon Centre as a leader in its field. Tom de Castella finds out why.

A 15-year-old young man is found kicking cars drunkenly one night. He is taken to A&E where health professionals realise this isn't a one-off. It turns out the young man has been drinking heavily since the age of 12. He has an alcoholic mother and an absent father. What hope is there?

At a discreet-looking Victorian house in Kentish Town, north London, professionals believe they have found the answer. The Brandon Centre is a voluntary organisation that began more than 40 years ago offering contraceptive services to young women. Now it offers a range of services to young people, from sexual health advice to counselling and specialist mental health therapies.

The teenager picked up for kicking cars has been helped by being placed in multisystemic therapy (MST), a familyand community-based treatment programme that addresses the underlining causes of problem behaviour by looking at all aspects of an individual's life from home and parents to school and their friends.

Brandon's director Geoffrey Baruch credits MST with turning the young man's life around. "He was drinking himself to death. But the intensive focus of MST in working with his parents has led to a complete change in his use of alcohol and drugs," he says.

In February, the government's mental health strategy No Health Without Mental Health recognised the importance of providing therapies for young people, citing the Brandon Centre as an example of best practice. For outreach worker Jessica Thom, Brandon's warm, informal approach is what sets it apart. The centre doesn't look like a "facility" but a rambling, four-storey Victorian house. "It's friendly and welcoming. It doesn't feel scary or clinical: you don't have to go through numerous doors to get anywhere."

As the outreach worker, she spreads the message about the centre's work through schools, hostels, pupil referral units and youth clubs. "One of the nice things is it's so easy for the young people to refer themselves," she says. "They don't have to go to their GP. They may come to the sexual health service and be referred over to the counselling service."

The centre offers two distinct approaches to young people who are struggling with mental health problems - talking therapies for those with problems such as depression, and MST for those with behavioural problems. About half of the first group are self-referred; the other half by families, mental health services, social services and schools. It might be the case that a child is unhappy, unwilling to go to school or self-harming. They are offered either cognitive behaviour therapy or psychoanalysis, although Baruch chuckles at the latter's "tell-me-about-your-mother" reputation from the movies. "The kind of work our therapists do here is very adapted to this age group and they are experienced at working with young people."

Problems dealt with

In 2009/10, Brandon's psychotherapy service provided therapy to 301 young people. Sixty-five had suffered bereavement, 48 had a substance misuse problem, 45 were helped for self-harm, and 25 had attempted suicide among other issues. Eighty-seven per cent of young people who completed the Commission for Health Improvement Experience of Service questionnaire stated that the overall help provided was good. One young person commented: "I feel really positive when I come out of my sessions. I feel the issues I have are being dealt with and that I am understood."

So how did the centre come to deploy MST to address behavioural problems? "We came to MST because we could see that the usual approaches to working with young people involved in antisocial behaviour were getting nowhere," says Baruch. "It missed out something terribly important - what was going on outside the clinic when they were at home."

In 2003, the centre began a six-year trial of MST in partnership with Camden and Haringey youth offending services. The trial was backed by money from two foundations and the Department of Health, and evaluated by University College London. Their analysis will not be formally published until the end of the year but provisional findings show that 18 months on from treatment, 90 per cent of the young people who received MST have not reoffended compared with 63 per cent in the control group which received conventional treatment. "It has been especially effective with non-violent offenders," Baruch says. "With violent offenders there was a trend in favour of MST but it was not significant."

In the trial, the young people came via the youth offending service on either a referral or supervision order, although they needed their parents' consent.

Its success, in a nutshell, is about finding out how the young person's family works so that any factors that contribute to antisocial behaviour can be changed, he says. It takes place not in the centre but in the family's home, with the MST team available every hour of the day to fit in with the family's needs. For instance, one family that runs a shop has arranged to meet its therapists at seven o'clock on a Sunday evening. For every problem identified - swearing, not attending school, failing to do household chores - a contract is drawn up which the parent must enforce. The therapist works with the family, liaising with drug and alcohol workers where necessary, but at the end of the intensive treatment of about five months, it is the parents who must take ownership. "If there is a problem getting the child into school, it won't be done through the therapist, it'll be done by the parent," says Baruch. "Parents will be shown how to improve their contact with the school. It's about social skills and trying to bring warmth into the home."

For instance, one client James, was 16 when Camden youth offending service referred him to the Brandon Centre's MST trial. He was out of school having assaulted his teachers. His most recent offence was assaulting a member of the public and he had regularly been aggressive at home, including once hitting his mother.

Goal setting

His MST therapist came up with four goals: to stop offending, cease all physical aggression for four weeks, cut swearing and physical aggression by 80 per cent, and carry out household chores. James started treatment in August 2010 and by the time he finished in January he had met all his goals and was engaged in more constructive activities.

"The hostile relationship between him and his mother has become much warmer and both expressed their gratitude to the therapist," says Geoffrey Baruch, director of the Brandon Centre. "He is not back in school but he is studying for six GCSEs this summer."

MST is expensive. The Brandon Centre charges £9,500 per young person and with an estimated 30 cases annually, the MST team costs £285,000 a year. But the future for MST looks promising. In January, MP Graham Allen's report Early Intervention: The Next Steps recommended the use of the therapy, noting that US studies found that it reduces long-term re-arrest rates by between 25 and 70 per cent and the need for out-of-home placements for young people by between 47 and 62 per cent.

Sarah Brennan, chief executive of mental health charity Young Minds, believes there is great potential in MST. "Involving the family like this is very powerful; it's change that sticks," she says. "It's expensive at the point of delivery but cheap in terms of society and young people's wellbeing. If you can stop a young person offending it saves us millions."

She also would like to see more voluntary projects such as Brandon receive core NHS funding for mental health therapies. "What makes the Brandon special is that it is both a specialist mental health service with core child and adolescent mental health service and primary care trust funding and is very much a community organisation. There are very few of these centres around."

She adds that such community-based centres help to reduce the stigma surrounding mental health services. "Young people don't see themselves as having a mental health problem: they see it as a problem with home or school or exams or housing," she says. "You often have to go in through another issue to get to the mental health aspect so it's ideal to have a centre that provides all sorts of things. It shouldn't just be about psychotherapeutic interventions."

But in the age of cuts, can the Brandon centre keep providing such services? It has an income of £1m a year, with £420,000 coming from central government, £275,000 from councils and £205,000 from primary care trusts. With a wry smile, Baruch says he's "always worried" about funding. But the shift of government policy in recent years towards talking therapies, sexual health advice and now MST gives him hope. The centre is launching two adaptations of MST for young sex offenders and also drug users and he hopes their MST services will be commissioned by councils across London.

In the longer term, he's watching with interest a nationwide trial of MST called Start (Systemic Therapy for At-Risk Teens), which has been running for more than a year. "It's a much bigger trial involving 700 young people across nine different local authority areas. So we're hoping it will tell us much more about which groups MST is most effective with."

TREATMENT AT THE BRANDON

Types of problems displayed by young people who use the Brandon's psychotherapy services