Charlie Howard is taking mental health work out of the clinic and onto the streets, successfully engaging young people involved in gangs and antisocial behavior. Charlie is revolutionizing the way mental health services are delivered to these excluded young people, removing existing barriers to access and bringing all stakeholders together for a new, preventative solution to serious youth violence.
The New Idea
Charlie is transforming mental health delivery for the most marginalized young people, bringing “street therapy” to where they are, when they need it. Charlie founded MAC-UK to take mental health work out of the clinic and into the context of young gang members’ daily lives. Her team of mental health and youth workers remove the stigma and logistical obstacles around seeking help, with young people deciding when, where and for how long they would like to meet. Street therapy can take place in stairwells, at a bus stop, or while a young person is waiting to be seen in court. In this way Charlie is making mental healthcare accessible to deprived young people who are most in need of support but least likely to access it.
Unlike other mental health services MAC-UK does not take any referrals from professionals such as doctors or social workers. Instead young gang members who are involved in crime and highly antisocial behavior and who suffer from poor mental well-being self-refer. These young people have a history of non-engagement with services but join because they are given the opportunity to invent and run a project they find interesting, whether that might be setting up a boxing club or writing and recording music. MAC-UK staff work collaboratively with the young people on their chosen project, helping them to develop leadership and employment skills. By using youth led activities as tools to successfully engage young people aged 16 to 25, Charlie has found a mechanism to build trusting relationships with gang members over time. At their own pace they then peel off into one-on-one street therapy sessions in their local area. Through this highly flexible model, Charlie is transforming mental health delivery, working intensively for up to three years with the 5 percent of young people who commit 50 percent of youth crime.
Instead of just focusing on expanding the delivery reach of MAC-UK itself, Charlie’s long-term strategy is to fundamentally change the way mental health services are delivered to the most marginalized young people. In fact, Charlie’s aim is to shut down MAC-UK’s direct delivery work within ten years once her model has been adopted by mainstream mental health services. To this end, she has evolved street therapy into a multistakeholder model called Integrate. Here, Charlie unites the various statutory bodies that are falling short of their aims to engage young offenders and reduce youth crime, and creates a more effective multiagency team that delivers MAC-UK’s model locally.
Serious youth violence and adolescent antisocial behavior and crime is increasing across the UK, brought to world attention in the 2011 riots. In London alone, there are 250 recognized gangs who carry out 50 percent of all shootings and 22 percent of all serious violence. To date, the criminal justice system’s approach to curb the growth of serious youth violence by increased policing and sentencing has been largely unsuccessful. This comes at a huge cost to the state, with the UK spending £1.2 million (US$1.59M) every time a young person is stabbed.
Behind the statistics the vast majority of offenses are carried out by a small minority of youths, who often come from the most disadvantaged backgrounds. Mental illnesses such as clinical depression, post-traumatic stress and psychosis are three times more prevalent in this group than in the rest of the population, but present unusual symptoms in the form of aggression and violence. As a result their conditions often go undiagnosed, with one in three young offenders having an unmet mental health need at the time of their offence. This statistic shows the extent to which mental health agencies are failing to reach and engage with young gang members. In fact, they are an excluded group for whom mental health services are simply inaccessible. Past bad experience with the authorities and fear of imprisonment leads to a distrust of public services. For young men in particular, social stigma and fears of being called a “snitch” make asking for help an inconceivable task.
Yet, the current mental health system is set up in such a way that young people must actively seek support. What’s more, mental health agencies lack the flexibility to be compatible with young people’s daily lives. Their services are confined to specialist clinics, outside of young offenders’ local areas or within another gang’s “patch.” Youths must attend fixed appointment hours which do not fit with their chaotic lifestyles and if they miss just two appointments they are removed from the NHS booking system altogether. Subsequently these young people are typically overlooked until their mental health problems have escalated and/or offending careers established which is arguably far too late. The current structures to provide mental health services are therefore too rigid to offer a real solution for gang-related youths’ specific mental health needs.
At present, the issue of youth crime and violence is seen as more of a policing priority than a public health priority. Yet increasing enforcement alone will not tackle the underlying behavioral problems of young gang members. Indeed despite coming into regular contact with the criminal justice system, it is clear that the mental health needs of young offenders are not being properly identified and treated. A lack of coordination between different government agencies therefore means that many gang members are falling through the cracks of the system.
Charlie’s vision is to make mental health services accessible to the most excluded young people. Her ultimate aim is to radically transform how mental health services are delivered. Firstly, by changing the way that statutory services engage with those involved in antisocial behavior and offending, secondly, by training other organizations to better understand young people’s mental health needs and thirdly by influencing government policy concerning gangs and youth violence.
The first part of Charlie’s strategy focuses on changing the provision of statutory mental health services for young gang members. Through the Integrate model, Charlie is structuring mental health services in a way that they can respond flexibly to the chaotic needs of young people. To date, four pilot sites have been commissioned across London in high deprivation, high crime areas. Each Integrate site brings a dedicated team together, led by an expert clinician trained by MAC-UK, and staff members from the police, the Local Council, and the National Health Service. Together, they deliver MAC-UK’s Integrate model and after a maximum of three years of experiential training the project becomes entirely run by statutory services. By working with all of the key stakeholders in each local authority, MAC-UK is able to fundamentally change the provision of mental health services, whilst at the same time bridging young gang members into other statutory services. The Integrate model has been commissioned by both mental health trusts for its success in diagnosing and treating the mental health needs of excluded young people, as well as by local authorities for its impact on reducing serious youth violence and re-offending and engaging young people in training, education, or employment.
Since launching in 2008, MAC-UK has already been held up as an example of best practice by the Department of Health, the Department for Work & Pensions and the Home Office. Charlie has turned down funding to roll-out the Integrate model because she wants to complete a full cost-benefit analysis and develop a thorough evidence base for the methodology before scaling the number of clinical sites. She is therefore working in partnership with the Centre for Mental Health, who has agreed to carry out an external three-year evaluation of the Integrate model. Once this is complete Charlie aims to scale the Integrate model across the UK and eventually across the world. She believes that the Integrate model has the potential to make mental health promotion and treatment available to all excluded groups, not just young offenders. Charlie is currently proving that the model is effective when working with one of the most challenging target groups, young gang members, but ultimately sees her work having far-reaching effects throughout the mental health sector.
The second part of Charlie’s strategy is to work at an organizational level to train others in MAC-UK’s methodology and enhance professionals’ understanding of young people’s mental health needs. Through the Integrate model, MAC-UK has therefore pioneered a training program delivered in part by young gang members, which is targeted at social workers, hostel workers, prison wardens, teachers, and the police. The training is tailored to the specific needs of each audience and includes modules on building trust, mental health and youth offending, Street Therapy, youth led working, substance abuse, anger management, personal safety, and responsive risk management. By involving young gang members who have been supported by MAC-UK in delivering the training, Charlie gives practitioners real insight into the direct experiences of young people, as well as providing the youths with a chance to voice how they want to be treated, gain employment skills, and earn a modest income. To date MAC-UK has trained over two thousand professionals across the country. Currently, demand for training dramatically outstrips MAC-UK’s capacity to deliver, so Charlie along with three of the first gang members to go through the Integrate model have set up a social enterprise called Mini-MAC which works to promote mental health to vulnerable and at risk young people through music in schools and pupil referral units and deliver training by young people. Charlie foresees the training growing in parallel with MAC-UK, as those delivering the Integrate model in new sites across the country will first need to be taught and accredited by young people who’ve been through the program to ensure that the model retains its original ethos. In ten years time Charlie believes that the direct delivery of the Integrate model will be run by statutory services and the training course will play an even more important role in maintaining the quality of its implementation.
The final part of Charlie’s strategy is to ensure that mental health promotion and treatment is at the heart of all interventions for young people who offend. As a member of the Expert Advisory Panel to the Home Office for Ending Gang and Youth Violence, Charlie is successfully highlighting the need to address mental health issues in relation to youth crime and violence. Through this position, she is therefore playing a key role in influencing government policy on how to bridge the gap between the criminal justice and mental health system. What’s more, she is advising the government on how to build effective multi-agency relationships at the local level that can deliver appropriate services to excluded young people.
From a young age, Charlie was fascinated by tough ethical questions and understanding social inequality. At the age of 15 she started volunteering regularly at a homeless shelter, where she became friends with a number of residents and talked with them about how they had come to be homeless. This experience motivated her to study sociology at university, completing a dissertation on the link between alcoholism and homelessness in males. Whilst at university Charlie decided to take a part-time job at a Medium Secure Unit for young people, where she worked closely with sex offenders who had learning needs. She became interested in the role the environment played on mental health and vice versa and decided to convert to studying psychology, completing her clinical psychology doctorate in 2007.
Charlie found her training frustrating as she began to realize that neither psychology nor sociology in and of themselves held the answers. As part of her thesis, Charlie created an observational study of a community in Camden with high levels of youth violence, whom she realized had written off the young local gang members as “destined for prison.” She became determined to engage with these young people and find a way that they could gain access to mental health services.
Charlie therefore started researching the DOME Project in New York, which worked with gang members from the Bloods and the Crips, two of the most influential and dangerous gangs in the US. She learned first-hand from their work and persuaded her university to endorse a placement scheme in the US, becoming one of the first psychologists in the UK to do so. Whilst there, Charlie chose not to work with the young people in a clinic. Instead she asked the young gang members to show her around New York from their perspective. This provided her with a fantastic insight into what it had been like for them growing up and offered her the opportunity to start doing therapy on the hoof.
Upon her return to the UK, Charlie knew that she could not go back to delivering services in a clinic and be part of a system that wasn’t working for this group. She instead returned to the Camden community she had studied in her thesis, and started “hanging out” at the excluded gang’s favorite fish and chip shop. To begin with, Charlie was insulted and spat at, and it was only after six months that one of the gang members finally spoke to her. Charlie said “I need your help. I know there are lots of things out there for you, but they’re not working. I think you know what would work.” This young man became Charlie’s bridge to the rest of the gang, and would later help Charlie develop MAC-UK as an organization and as a model to engage youth with mental health issues.