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Mental Health Programme Report

T

he climate surrounding mental health service provision in 1993 -

when the City Parochial Foundation’s Mental Health Programme

was launched - was one of great change. Statutory purchasers and

providers had been increasingly focusing on the implementation of

care management guidelines in social services, and the care

programme approach in the health service. At the same time, a

number of high profile inquiries into individual examples of failures in

community care were associated with a great deal of negative media

coverage. Heightened public fear of the dangerousness of the

mentally ill - coupled with suspicion of the progressive policy of

transferring services from the large asylums into the community - were

reflected in the Secretary of State for Health’s response to the

Christopher Clunis Inquiry: ‘the pendulum has swung too far’.

Reprovision of psychiatric services into the community nevertheless

continued apace, as the Government increasingly endorsed a needs-led

service, responsive to market forces, and tempered by the involvement

of mental health service users in the monitoring and strategic planning

of the changing services.

The chequered history of community care

The shift towards community care had begun in the 1950s, with the

first large scale closures of the mental asylums in the early 1960s. In

1975 a discussion document, ‘Better Services for the Mentally Ill’

1

had

encouraged further moves away from large psychiatric hospitals whilst

at the same time recognising that there were insufficient services in the

community to support people with mental health problems.

The 1990 NHS and Community Care Act placed a requirement on local

social service and health authorities jointly to agree community care

plans for the local implementation of needs-based services for

long-term, severe and vulnerable psychiatric patients. Subsequent

DHSS Inspectorate guidance

2

defined the concept of ‘care

management’ - a change which marked the introduction of the

purchaser/provider division within social services, with the care

manager identified as a purchaser of services, as opposed to a

provider. In line with the Government’s free-market ethos, 85% of the

monies allocated to implement the Community Care Act, the Special

Transitional Grant, had to be spent in the private or voluntary sectors.

1

Department of Health and Social Security (1975) Better Services for the Mentally Ill. London: HMSO.

2

Department of Health and Social Services Inspectorate (1991) Care Management and Assessment.

S

ummary of Practice Guidance. London: HMSO.

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Mental Health

Services in the

1990s

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Mental Health Programme Report

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Alongside the 1990 Act, the Department of Health introduced the

‘Care Programme Approach’ (CPA)

3

. This was designed ‘to provide a

network of care in the community’ for mentally ill people, both to

ensure that they had adequate support and to minimise the risk of their

losing contact with services. The essential elements of the CPA were:

•

systematic arrangements for assessing the health and social

care needs of people accepted by the specialist psychiatric

services

•

formulation of a care plan which addressed the identified

health and social care needs

•

appointment of a key worker to keep in close touch with the

patient and monitor care

•

regular review, and if need be, agreed changes to the care

plan.

Problems arose as a result of there being two separate systems for

delivering mental health care, represented on the ground by the social

services care manager, designed to be a resource manager, and the

health services key-worker, engaged in service provision. Subsequent

Government guidance

4,5

was intended to resolve the

difficulties, which were further complicated by the rise in GP

fundholding.

Public fears and the media

Community care had acquired an unpopular image with the public. A

1993 survey of media coverage of mental health issues by the Glasgow

University Media Group found that two-thirds of items related mental

distress to violence, whilst audience research by the same group

confirmed the belief that the strong link between mental health and

violence in the public mind was largely derived from the influence of

the media

6

.

At the end of 1992, three devastating incidents served to reinforce the

association of dangerousness with mental illness, and with a

perceived inadequacy of community care arrangements for the

mentally ill: Ben Silcock, a discharged psychiatric patient with a

3

Department of Health (1990). The Care Programme Approach for People with a Mental Illness.

London HC(90) 24/LASSL (90)11 DH.

4

Department of Health (1995). Building Bridges: a guide to arrangements for inter-agency

working for the care and protection of severely mentally ill people. London: DH.

5

Department of Health (1994). Guidance on the discharge of mentally disordered people and their

care in the community. London HSG(94)27/LASSL(94)4 DH.

6

Philo G, Secker J, Platt S, Henderson L, McLaughlin G and Burnside J (1994). The Impact of the

Mass Media on Public Images of Mental Illness: Media Content and Audience Belief. Health

Education Journal 53; 271-81.

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diagnosis of schizophrenia who climbed into the lion’s den at London

zoo and was badly savaged; the killing of Jonathan Zito by discharged

psychiatric patient, Christopher Clunis; and the murder of 54-year-old

former policeman, Frederick Graver, by a former psychiatric patient.

These incidents and their reporting in the press influenced the

Government’s 10-point plan (August 1993), which included new

guidance on the discharge of mentally disordered people into the

community, the establishment of supervision registers for patients

deemed a risk to themselves or others, and a new power of

supervised discharge.

The rise of the voluntary sector

The introduction of managed markets, in the health service in

particular, had shifted the emphasis of the statutory services towards a

more needs-led approach, giving purchasers the power to divert funds

away from secondary service providers. And increasingly, Government

directives were specifying that local purchasers and providers should

consult with service users regarding overall improvement in local

services, as well as in their own care.

In the prevailing climate, the voluntary sector was uniquely placed in

several ways to provide much of the social support frequently

identified by service users as a key element of mental health care.

Voluntary services were at once competitive and relatively flexible in

their approach, making them attractive to purchasers and users alike.

And within the voluntary sector, the rise of the user movement - with

its emphasis on self-advocacy and empowerment - was a highly

significant and innovative development.

With its beginnings in the early 1970s in the anti-psychiatry movement,

the user movement had grown exponentially. Over 10 years since

1985, the number of user groups rose from less than a dozen to an

estimated 350 plus at local, regional and national levels

7

. The

movement played a leading role in the Government-appointed Mental

7

Campbell, P (1996) The history of the user movement in the United Kingdom. In: Heller T,

Reynolds J, Gomm R, Muston R, Pattison S (eds). Mental Health Matters. A Reader. London:

Macmillan.

Mental Health Programme Report

page 4

Health Task Force, set up in 1992 to facilitate the development of

better services in the community. At a local level, representatives from

user groups were becoming more involved in service planning,

evaluation and training, and in providing advocacy and support, as

well as a platform for the user voice. User groups both represented

and modelled radically new approaches to mental health services

based on the needs and wants of service users.

What did users want?

Broadly, users were calling for a decreased emphasis on illness and

greater recognition of their social needs. Decent housing, adequate

income and more opportunities for paid employment were high

priorities. Beyond this, acceptance was the key issue: to be listened to

and have their views taken seriously. To be recognised as equal

citizens, to be better informed about treatment and services, and to

have more opportunities to participate in the development and

management of services that reflected these values. Community-based

services, despite their shortcomings, were consistently preferred and

engaged with by service users over hospital care

8,9,10,11

.

The mid 1990s was an opportune time for creating a user-friendly

future to support those in mental distress. Hopefully projects such

as those outlined in the following pages will have helped to support

that future.

8

Audit Commission (1994). Finding a Place. London: Audit Commission.

9

Beeforth M, Conlan E, Field V, Hoser B and Sayce L (1990). Whose service is it anyway? London:

Research and Development for Psychiatry.

10

Rogers A, Pilgrim D and Lacey R (1993). Experiencing Psychiatry: Users’ Views of Services. London:

Macmillan.

11

Rose D (1996). Living in the Community. London: The Sainsbury Centre for Mental Health.

Why a Mental Health Programme?

C

ommunity care was a recurrent theme in the Report of the City

Parochial Foundation’s Policy for Grants 1992-1996. As part of its

five yearly policy review in 1991, the Foundation had commissioned a

policy paper on community care to provide background information

on the needs for care in the community in London, and recommenda-

tions as to funding. This paper identified six broad concerns:

•

carer relief, respite and support

•

physical access and transport to mainstream services

•

enabling voluntary sector representation on planning bodies

•

self-advocacy projects

•

mental health day-care services

•

support services for people in mental distress, particularly people

from the Afro-Caribbean and Asian communities, and training of

therapists from these communities.

Racism and the refugee situation were also highlighted as priorities for

the future.

Three deciding factors motivated the Foundation’s decision to fund a

broad-spectrum mental health programme. First, the Foundation had

received few grant applications in the mental health field in the recent

past. Second, there were growing concerns about the needs of clients

and their families in this area. And last, the statutory services for those

with mental health problems were in the process of radical rethinking

and re-structuring, with the potential for adverse effects on the

provision of services to those in great need, such as the homeless

mentally distressed.

Priorities and projects

Preparations for the Foundation’s Mental Health Programme began in

1993. Early in the year, a specially convened advisory panel of mental

health experts was invited to recommend priorities for grants within

the programme. Four particular concerns were identified.

•

Women experiencing mental health problems (of all ages).

•

Young people with mental health problems, particularly young

people from black and minority ethnic communities, including

refugee communities.

•

Accommodation projects concerned with providing specialist help

for homeless people with mental health problems, especially

those with continuous ongoing needs.

•

Self-advocacy schemes and groups that brought together

consumers of mental health services to say what they felt about

those services and the way they were operating, with a view to

bringing about improvements.

Mental Health Programme Report

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The Mental

Health

Programme

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These priority concerns were put to a public meeting of people

involved in mental health organisations in June 1993. A total of 120

people attended the meeting and endorsed the choice of priorities.

Wide publicity about the availability of funds (up to £500,000 a year

over three years) for new work within the priority areas of concern

resulted in 90 approaches for grants being received by the Foundation.

Over half fell outside the stated priorities. Of the remainder, 20

organisations were invited to meet Foundation staff and 17 of these

were invited to submit full applications. Nine organisations eventually

received grants. The Foundation received no applications from

organisations working with the homeless mentally ill, thus the funds

allocated all went to groups working within the remaining three

priority areas of concern. These were:

•

The Manic Depression Fellowship

•

Nafsiyat Intercultural Therapy Centre

•

Peter Bedford Housing Association

•

Mental Health Media

•

Croydon Mental Health User Group

•

Mind in Tower Hamlets

•

Horn of Africa Counselling and Social Support Centre

•

Brixton Sanctuary

•

Islington Women’s Counselling Project

With the exception of the Horn of Africa Counselling and Social

Support Centre, which received funding for a feasibility study only,

these organisations all received three-year grants from the City

Parochial Foundation for specific mental health projects. The Brixton

Sanctuary and the Islington Refugee Project of Women’s Counselling

projects both closed prematurely (further information on page 7). The

remaining six projects, the services they have provided with

Foundation funding, the project outcomes, and the problems encoun-

tered during the course of development, are described in the following

pages of this report.

Monitoring and reporting

The Foundation outlined a number of monitoring and reporting

systems, both to monitor the Mental Health Programme as a whole,

and to assess individual projects comprising the programme. These

included the following elements.

•

Group meetings of the all organisations funded at the end of the

first six to ten months of the programme, and thereafter twice

yearly, to discuss issues and problems and exchange

experiences.

•

Visits to the individual projects by the Policy and Monitoring

Officer, Dr Maknun Gamaledin-Ashami, every six months to

assess progress.

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Mental Health Programme Report

Mental Health Programme Report

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•

All projects to copy project-related documentation to the Policy

and Monitoring Officer on a regular basis - and to inform him of

any management changes.

•

A short questionnaire to be completed every year by the

managers and key workers in the individual projects, aimed at

assessing the effectiveness of the grant, its impact and lessons

learnt.

•

Annual reports to be prepared specifically by the individual

projects for the City Parochial Foundation. These to include a

section detailing the profile of clients using the services.

•

The Policy and Monitoring Officer and the Field Officer

responsible for the programme to prepare an annual monitoring

report for submission to the Monitoring Sub-Committee and other

relevant City Parochial Foundation committees.

Projects that ended prematurely

BRIXTON SANCTUARY

Brixton Community Sanctuary applied for and received, in 1994, a

grant of £77,735 over three years to employ a community outreach

worker who would particularly work with women. This was an

important initiative as members of the Sanctuary felt at the time that

women were not well represented amongst their regular membership.

Sadly, the organisation suffered from the effects of one member of

staff’s ill health and difficulties with premises. As a result, the project

came to an end when the remaining worker moved to another job in

1996.

ISLINGTON WOMEN’S COUNSELLING PROJECT

The Islington Women’s Counselling Project received a grant of £92,771

over three years to employ a refugee worker to work with younger

women. This exciting work began in June 1994, but unfortunately

significant staff changes led the project leaders reluctantly to decide in

September 1995 that they could no longer continue the work as

originally envisaged.

page 7

FEASIBILITY STUDY: THE HORN OF AFRICA COUNSELLING AND

SOCIAL SUPPORT CENTRE

This organisation received a grant for a feasibility study to examine the

extent of mental health problems amongst refugees from the Horn of

Africa, the appropriateness of existing statutory and non-statutory

provision, and the health and social care needs experienced by people

from the Horn of Africa suffering mental distress. The research,

completed in 1995, successfully identified the particular problems faced

by refugees from the Horn of Africa with mental ill-health. These have

subsequently been widely acknowledged and several agencies,

including the Mental Health Foundation, are working to relieve mental

health and social care difficulties faced by refugees, including those

from the Horn of Africa.

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Mental Health Programme Report

M

anic depression, also known as bi-polar affective disorder, is

characterised by swings in a person's mood from high to low -

euphoric to depressed.

In the manic phase, the person has excessive amounts of energy and

feels little need for sleep. At these times they may behave in ways

which can have serious consequences when the episode is past, for

example leaving their job, spending a lot of money, or giving away

their possessions. During a depressive episode, there is a feeling of

hopelessness and despair, of lethargy, broken sleep, overwhelming

negativity and difficulty in carrying on with the activities of day-to-day

life.

These are, however, only episodes. People with a diagnosis of manic

depression can have long periods of time without experiencing these

problems, and many sufferers lead useful and productive lives. In

addition, user-run groups like MDF have been instrumental in helping

people with manic depression learn how to cope better with the

problems arising from it, through self-management techniques and

through the support and advice offered in MDF self-help groups.

The Need for an Expanded MDF London Network

Manic depression, according to World Health Organisation figures,

affects 1 in 100 of the general population at some time in their life.

Despite this, it is a condition about which there is considerable

ignorance among the general public. As a consequence, people with

manic depression can feel isolated and experience prejudice.

MDF supports an expanding network of self-help groups nation-wide.

However, its presence in London in the early 1990s was under-

developed, particularly in inner city areas. A total of only nine London

MDF groups existed at the start of the project in 1994. In such a large

centre of population, there was an obvious need for outreach to

people living with manic depression, by developing the network of

MDF self-help groups in the Greater London area.

Mental Health Programme Report

page 9

Manic

Depression

Fellowship:

Expanding the

MDF Self-Help

Network in

Greater London

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Self-help can mean two things. It can refer to an individual’s efforts to

cope better with whatever is troubling them, by educating themselves

about the nature of their problem, for example, or by learning new

ways to handle its effects.

Self-help can also involve meeting together with a group of people who

have been through similar problems to offer each other mutual support

and understanding. Such groups are known as self-help groups or,

sometimes, support groups. Through sharing their experiences,

members of MDF self-help groups learn how to cope better with the

effects of manic depression. Collective self-help not only assists group

members with managing their condition, but also enhances their

social lives and encourages them to campaign to improve services.

People who attend a self-help group may find that it is the only space

where they can be honest about their symptoms or fears without being

thought of as odd by the people listening. These groups do a great deal

to lessen the sense of isolation for MDF sufferers and their families and

to reduce their fears about not being able to cope.

Self-management of manic depression describes the process of

understanding one’s mood swings, the effects they have, and at what

times and how often they are likely to occur. This helps individuals to

recognise signs of an approaching mood swing and take steps to cope

with it better, leading to improved stability and a greater sense of

control.

page10

The London Project

City Parochial Foundation made MDF a grant of £132,732 over three

years to expand their services in Greater London, by appointing a

director with special responsibility to:

•

raise awareness of MDF services in Greater London

•

provide advice, information and access to MDF self-help groups

in Greater London

•

expand the network of MDF self-help groups throughout the

Greater London area

•

develop links and services appropriate for black and minority

ethnic communities affected by manic depression

•

ensure continued funding for the project and the local groups at

the end of the three year City Parochial Foundation grant.

In a region that has a population of nearly seven million people, with

32 boroughs and 68 separate NHS Trusts, this represented a formidable

task.

Mental Health Programme Report

Self-help and self-

management

Expanding the MDF Group Network in Greater London

An MDF Director for Greater London was appointed in March 1995.

Selection of a part time administrative assistant followed in November

1995.

The Director was responsible for all MDF development work in

Greater London. This focused initially on the development of new

MDF groups in under-developed areas. A target of six new groups by

the end of year one was successfully reached.

Kingston MDF Group

launched May 1995

West London MDF Group

launched May 1995

Wandsworth MDF Group

launched September 1995

Bexley-Thamesmead-Greenwich

MDF Groups launched

September 1995

Ealing MDF Group

launched March 1996

Hackney MDF Group

launched March 1996

Four further groups were subsequently established.

Enfield MDF Group

launched May 1996

Hampstead MDF Group

launched October 1996

Twickenham MDF Group

launched March 1997

Brent MDF Group

launched March 1997

Development work has since continued in Haringey and Merton.

How the Project Worked

To begin an MDF group in a new area, the Project Director would start

by making contact with local people to assess the level of interest.

This would include both MDF members in the area and professionals,

in order to access users of the mental health services locally who might

not know about MDF. Directories of local mental health services,

including other voluntary organisations, were further sources of

potential group members.

After consultation and discussion, a preliminary meeting might be set

up, where people would be invited to find out about MDF, self-help

groups and self-management of manic depression. If a number of

people were interested enough to want to start a group in the area, the

Project Director would work with them to help them develop their

own systems for running the group and to sort out the practicalities.

She would then provide ongoing support for group facilitators as the

group grew. She would also offer opportunities to network with other

MDF groups and their facilitators through a monthly Greater London

MDF Bulletin and quarterly Network Days and Group Training Events

for the region.

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What Made a Group Work?

The success of a group seemed to depend on a number of different

factors. For instance, if a group relied on one key individual to lead it,

the absence of that person for any length of time could lead to the

group’s dissolution. One way of preventing this was shared

leadership, with a number of people, at least two, taking turns to lead

the group. This arrangement also served to relieve stress for people

who were interested in becoming more involved but worried about

their ability to cope.

Having shared leadership, however, sometimes led to a clash of styles

or opinions as to what a group should be doing. The involvement of

the Project Director, as a neutral mediator, was of key importance in

enabling different views to be heard and consensus to be achieved.

For a group to be successful, members have to be sure that

confidentiality will be maintained, thus new groups were encouraged

to have a clear statement to this effect to which all members agreed to

adhere.

Project Successes

The availability of part-time administrative support from an efficient

and reliable assistant was extremely valuable in allowing the Director

to concentrate on the development and training of MDF groups.

MDF’s Greater London membership increased by almost 50% since the

start of the project, from 820 to 1,196 members. This required a great

deal of networking and public relations work on the part of the

Director - travelling around, talking to people and distributing leaflets

about MDF.

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Mental Health Programme Report

“The Ealing group is beginning to thrive. We have a core membership

of 12 to 18 people who attend on a regular basis. At our last meeting,

members were still chatting to each other at 9.30 p.m., half an hour

after the consultant psychiatrist who came to speak to us had gone

home. He gave a very interesting talk. Four new members joined that

evening and it would seem that regular talks from various agencies

will engender new interest from outside parties and encourage

additional membership.

It is the intention of the group to be as self-reliant as possible, and to

organise our own speakers and so on, but we also acknowledge the

superb back-up we receive from all the staff at Kingston-Upon-Thames.

Ideally we would like a few more female and ethnic minority

members but we are optimistic that this wish will come to fruition in

the near future”.

Co-ordinator, Ealing MDF self-help group

Case study

Mental Health Programme Report

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The Director was able to work with MDF members in local areas and

effectively act as a catalyst for setting up new groups. The profile of

MDF was considerably enhanced as a result: the Fellowship became

much better known within mental health circles in the boroughs where

new groups were formed.

The training days were both innovative and well received. They had

not happened previously on a regional basis. MDF members much

appreciated meeting with members from other groups

throughout the London region to discuss group issues and business.

Future Work

There are still large areas of London in which MDF does not have any

self-help groups - or even very many members. Future work will need

to concentrate on those areas to make the most impact and to raise the

profile of MDF. Ongoing effort is required to support existing groups

as well as to help set up new ones. This strategy seems to have

worked well so far.

page 13

“The West London MDF - self help group aims to supplement psychiatric

and community care. Contact with other sufferers and carers is

immensely helpful in avoiding unpleasant experiences. By supporting

each other we also assist the community psychiatric system and

hospitals by leaving professional services and valuable bed space

available to others. We all want to live outside institutions and this

group helps enormously.

Twenty to forty sufferers and carers meet at the local community

centre on the first Wednesday of every month. For most of us it is an

invaluable support network - a place where the intense isolation

resulting from this illness can be relieved. Most of us see the group as a

lifeline, something the psychiatric services can only offer very

expensively. We offer support in times of crisis, by either phoning or

visiting in hospital members who have had to resort to an increasingly

unhelpful and overworked system of health and community care. We

also meet on the third Saturday in the month.

At group meetings literature and personal help is readily available to

both sufferers and carers regarding drug treatment, the nature of the

illness and how everyone copes with it. This help and information is,

sadly, not available anywhere else! The opportunity to speak with

other sufferers and carers to gain more insight into manic depression

and how it affects others around us is unique. We often invite speakers

who are professionally involved in treating or helping manic

depressives.

In just a year and half the West London self help group has achieved a

membership of 84 sufferers and carers”.

Co-ordinator, West London MDF self-help group

Case study

Training events will need to continue to develop team working and

facilitation skills, the lack of which appeared to be the common root of

difficulties among the self-help groups.

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Mental Health Programme Report

“When I first heard of MDF, I had just come out of a long bout of

depression lasting 18 months. My confidence and self-esteem were at a

low ebb. I hadn’t worked for two years and my social skills had become

redundant due to long periods of isolation. A lot of friends had

deserted me, and I them.

Going to the first meeting was a big step as I didn’t feel confident

amongst groups of strangers, but I was made to feel welcome and I

found for the first time that I was able to speak openly and frankly

about bi-polar episodes knowing that other people had been through

what I’d been through - different experiences, some funny, some tragic,

some downright horrendous. I did not want sympathy; just someone to

listen without prejudice.

The meeting took place in someone’s house around a big oval table

and was informal and friendly. Interesting and informative ideas

were being bandied about. I came away having made a few new

friends who I still keep in touch with, and with a positive vibe about

MDF.

I am now group co-ordinator in Enfield and we have attracted new

members from within the borough and from a neighbouring area. I

have since been to workshops on the media and mental illness and on

coping with manic depression, and I’ve attended a supper evening at

the Royal College of Psychiatrists.

I am now attending College in Tottenham studying Humanities and

Social Services. I hope to sustain the members’ interest in the Enfield

group, to attract new members, and to obtain as much literature and

information on the subject as possible”.

Co-ordinator, Enfield MDF self-help group

One person’s

experience

Mental Health Programme Report

page 15

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“I have really benefited from the support and companionship of

members of our self-help group. I cycle from mania through

depression twice a year and I have great difficulty keeping in touch

with reality. Three members of the group keep personal contact with

me and advise me on how my attitude - aggressiveness, moodiness and

withdrawal - appears to the world at large. They give me invaluable

help between visits to my psychiatrist. I have not even been close to

entering hospital since the group began.

To return the help extended to me I regularly help sufferers in crisis

and/or in hospital. Carers frequently need more help than the

sufferers, particularly when the latter has gone astray while suffering

mania. This is very time consuming but satisfying”.

Member, West London MDF self-help group

One person’s

experience

The Need for a Counselling Service for Young Refugees

A

s its reputation for intercultural therapeutic work grew, Nafsiyat

began receiving an increasing number of requests for help from

refugees. Lack of available resources at the time meant that these

requests could not be met. In 1992, research into the problems

experienced by young refugees, conducted by Nafsiyat together with

the Traumatic Stress Clinic, indicated that this group was particularly

likely to experience problems as a result of witnessing violence and

death, being separated from or losing members of their family, losing

their familiar culture, language and community, and being isolated at

school. Some young refugees were also thrust into the position of

being carers to other siblings, increasing their stress and worry. For

young refugees with families in this country, generational conflicts

resulting from the young person’s adaptation to English culture were

also a frequent problem.

Research into the availability of services indicated a widespread lack of

provision for meeting the emotional needs of young refugees, and

particularly an absence of counselling services in languages other than

English. Language needs were usually met through translation via

interpreters - an arrangement which could frequently be uncomfortable

as well as inconvenient. Little preventative work was happening.

Moreover, most young refugees in contact with services were already

displaying behavioural and emotional difficulties, often of a serious

nature.

In addition, young refugees were frequently facing stress resulting from

practical problems, such as higher than average rates of

unemployment; poorer access to training as a result of unmet language

needs; poor housing; and difficulties with their benefits claims and

legal status.

The Refugee Project

City Parochial Foundation made Nafsiyat a grant of £148,766 over three

years to establish a counselling project for young refugees. The aims

were threefold:

•

to provide direct psychotherapy, counselling and group work

services to young refugees

•

to develop support within refugee communities themselves by

training potential counsellors and therapists

•

to liaise with statutory and voluntary organisations to ensure that

the psychological and emotional needs of young refugees were

being met.

page 16

Nafsiyat:

Therapeutic

Work with

Young Refugees

Mental Health Programme Report

Mental Health Programme Report

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A therapist/counsellor was appointed as full-time Project Leader in

January 1995. The City Parochial Foundation grant covered her salary

and supervision costs, the salary of a part-time administrative assistant,

and contract payments for sessional therapists.

The project leader’s main roles were:

•

to co-ordinate the training and work of volunteer counsellors

•

to provide individual counselling/therapy and group work in

schools and colleges

•

to liaise with refugee community organisations and other

appropriate agencies.

How the Service Worked

The Project Leader began by building on Nafsiyat’s 1992 research, to

establish the needs of young refugees across London. Consultation

took place with diverse counselling agencies, black mental health

agencies, schools, colleges, youth clubs, and refugee forums and

community groups. The Refugee Project and its training opportunities

for potential therapists from refugee communities were publicised

through these networks.

From these beginnings, the project grew to provide a therapeutic

service taking into account the stresses faced by young people from

refugee communities, particularly the after-effects of trauma and loss.

Ongoing work with the wider refugee communities continued to

promote understanding and use of the service. Therapy was offered

in a manner that made it acceptable to young refugees; for example, it

would often not be referred to as therapy, and it might not take place

in a therapist's consulting room. Drama, art and play would

sometimes be used in addition to more conventional counselling

techniques. Clients were offered flexibility in choosing a therapist;

they were asked whether they wanted a man or a woman and whether

they would like to see someone who spoke their own language. Most

Eritrean and Ethiopian clients preferred to see counsellors who were

not from their own community, even though they might have found it

easier to talk in their own language, because of concerns over cultural

values, including issues of confidentiality.

page 17

Group work, less intensive than individual therapy, was conducted in

two schools and a sixth form college. Groups were run separately for

boys and girls where appropriate, and were scheduled within school

hours to make it easy for children to attend and to demonstrate the

importance and value of the groups from the point of view of the

school authorities.

The recruitment and training of volunteer counsellors was a major

focus. Seven volunteers started training with Nafsiyat in September

1995, and most started seeing clients under supervision from January

1996. The one-year training course looked specifically at counselling

issues for young refugees. Volunteers were encouraged to see the

training as part of their career development. Nafsiyat is a United

Kingdom Council for Psychotherapy (UKCP) recognised training

centre, the volunteers received a certificate at the end of their training,

and there was an option to progress to more advanced counselling

training.

In addition to the training programme, the Refugee Project ran training

and awareness raising sessions for outside agencies on the mental

health needs of refugees, particularly in the younger age groups.

There were more requests for this work than could be dealt with - the

majority coming from statutory mental health care agencies.

Almost all the work of the Refugee Project was focused on developing

skills within the refugee communities - in order for refugees

themselves to be able to provide services to their own communities in

their own language. Workers and volunteer counsellors were

involved in continuous evaluation of the project, whilst a refugee

advisory group fed back to ensure that the diverse perspectives of the

different refugee communities were represented.

page 18

Mental Health Programme Report

“The Project started being available for referrals from November 1995,

and we were been able to offer a range of services from January 1996,

when the volunteers had received an appropriate amount of

preparatory training. In total we reached 129 referrals to June 1997.

The central issue for many of our clients has been separation,

bereavement or loss. Almost all our clients have had family members

who have died, sometimes in violent incidents.”

Project Leader, Nafsiyat Refugee Project

Referrals

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Who Used the Service?

The Refugee Project offered counselling and therapy for 129 refugee

children and young adults aged 12-30, mainly from Ethiopia and Eritrea

(26%), Somalia (15%), Turkey and Kurdistan (9%), Iran (9%), Sudan

(5%), and Latin America (4%). The young people using the project

presented a wide range of needs: some were in distress and

displaying behavioural difficulties and sometimes physical symptoms;

others had more deep-seated emotional problems. Some clients

would be coping well with their day-to-day lives at school or college,

but experiencing emotional stress and problems to do with their status

as refugees; some of these young ones attended the centre, whilst

others went to groups at their place of education.

The project initially received more referrals of young women than

young men, but numbers subsequently roughly equalised.

page 19

“A 16-year-old client came to the Centre feeling very depressed, she had

left her parents in Africa and had come to England with a relative.

Once in England the relative was treating her like a servant, not

sending her to school and making her stay at home and look after his

children. The young woman's self confidence had been decimated by

this relative, and when she came to Nafsiyat she had a very low

opinion of herself. She also had a lot of anger towards everyone she

met, some of which was based on envy. She was described as having

behavioural difficulties. She saw an English-speaking therapist at

Nafsiyat on a weekly basis for 12 weeks, after which she was seen every

month until the counselling gradually ended. Throughout the

counselling she was able to talk about her pain and about the loss of

her whole family, and to see that she had a strong attachment to the

relative who was abusing her because he was the only link to her past,

and to the rest of her family back home. At the end of the counselling

this young woman became much more confident and is now living in

her own accommodation and attending college.”

“One referral was of an Turkish father and daughter, the young

woman's mother had died in Turkey, although the exact nature of the

circumstances are still unknown. The father and daughter were

having many conflicts about their roles. The father had culturally

specific expectations of how his daughter should behave, and she

compared her father to how she imagined white parents behaved

towards their daughters. The young women was considered to have

‘behavioural difficulties’. Both father and daughter were seen by a

Turkish-speaking counsellor on a weekly basis for 12 weeks. The

counselling helped them both to accept and mourn the death of their

mother/wife and to see how they were blaming each other for her

death. The loss of culture, language and social values was creating

conflicts for the family; once they began to see how these issues were

affecting them, they began to improve in their communication.”

Case study

Case study

Project Successes

Nafsiyat has always had a high standard of clinical work with clients.

The new work was the outreach work and forming the team of

volunteer counsellors from the refugee communities. Training of the

volunteers was particularly successful. The project was able to find

very high quality volunteers; all but two out of the seven original

trainees decided to stay on after the training, and they made a very

solid team. Nafsiyat thus met its criteria for the training - the

development of skills within refugee communities.

The outreach also worked well. The clients using the service were

exactly those for whom initial research had identified gaps in existing

services. They came from three groups. First, unaccompanied young

people - the 14 to 18 year-olds coming to this country on their own.

Second, the 19 plus age group (79 in total); this group lack any

statutory support, and they have deeper emotional issues than the

younger age group. There were several recent suicides amongst

refugees in this age group in London. Third, there were those

refugees (74) who did not speak English. Being able to offer a service

in the person’s language was found to be very important.

page 20

Mental Health Programme Report

“One young Eritrean man we saw was 24 years old. He had joined

the army at the age of 12 and had come to this country at the age of

18. He was referred by his doctor as being depressed. The client had

been in the country for six years and felt that this time had been like a

dream for him. He had become preoccupied with imagining that he

had a life-threatening illness; the doctors could not identify any

illnesses and had put him on anti-psychotic medication. Now that he

had settled he was having panic attacks and feeling very depressed. He

thought these emotions were linked to his past experiences of witnessing

and being involved with extreme violence, both in the army and in his

community.

His past history was one of being brave and coping with all events, and

as such he had found it very difficult to express his fear and sorrow

about the events that occurred in his life. This fear was now beginning

to take over and he felt afraid of everything, to the extent that he found

it difficult to work and live his life. He received therapy for over 6

months, and was subsequently considered for long-term treatment

after a psychiatric assessment at Nafsiyat. The counselling helped him

to talk about all his built-up pain, anger and most importantly fear.

He had witnessed people being killed from a very young age, but had

always had to be brave. In the counselling he was able to explore the

root of his fear, and address fear in his present life.”

Case study

Mental Health Programme Report

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FOUNDATION

Future Work

Throughout the project, Nafsiyat were asked to do a surprising amount

of training and supervision for other organisations. To mid-June 1997,

they ran 27 workshops, conferences and one-day training sessions

aimed at teachers, social workers and other counselling centres on

specific ways of working with refugees as well as providing

consultancy work. Nafsiyat found that teachers, for example, were

keen to help refugee children but they did not know what to do.

More training and workshop programmes are planned, as is continued

ongoing supervision with mental health professionals working with

refugees. If professionals learn how to cope with refugees hopefully

services will be more appropriate for refugee communities.

Nafsiyat would also like to train more people from refugee

communities. They will be running further training courses in future,

with the aim of providing more resources within the communities.

The hardest part of the work was establishing the project and getting

recognition. That done, Nafsiyat are now seen as somewhere to send

people. They have established trust - and that needs to continue.

page 21

P

eter Bedford HA has many years’ experience in running employ-

ment and training schemes for people living in its housing projects.

These schemes offer participants the opportunity to meet people, keep

busy during the day; earn money to supplement benefits; develop and

improve their skills; and subsequently move on to open employment

or training if they wish, with full support. The schemes are designed to

accommodate people whose reasons for wanting to work may be very

different. Many may just want the chance to be with others

during the day and do something interesting with their time. For

others, however, moving into open employment or earning decent

money are more important.

The Need for Women’s’ Employment and Training Schemes

In 1992, the Peter Bedford Trust set itself positive action targets to

increase the number of women living in Peter Bedford Housing. This

met with considerable success - and in the subsequent two years the

proportion of women residents increased from 21 to 30%. Once

established, however, the women began to demand a better range of

services more appropriate to their needs. In particular, they wanted

more and different work opportunities besides those already available

in canteen catering and in the carpentry and upholstery workshops.

The most frequent requests were for opportunities in administrative

work and sewing-related activities, which were viewed as offering the

most useful training to enable a return to open employment.

Consultation with other mental health agencies involved in developing

employment opportunities locally confirmed that there was heavy

demand from women both for training that would enable them to

move into administrative work and for work activities like sewing.

Lack of access to suitable training opportunities is a significant issue for

people with mental health problems - and together with stigma, acts as

a considerable barrier to their joining the job market One reason for

this lack is that training agencies and colleges are not geared up to

meet any additional needs for support that mental health service users

may have. A key feature of the Peter Bedford HA schemes was

therefore to offer women participants the opportunity to gain genuine

qualifications that were recognised on the open market.

page 22

Peter Bedford

Housing

Association:

Creating

Employment

and Training

Opportunities

for Women

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FOUNDATION

The Women’s Employment and Training Projects

To attract more women into the Peter Bedford HA work schemes

required new developments. The City Parochial Foundation made

Peter Bedford HA a grant of £159,066 over three years to set up

schemes offering employment and training for women in office

administration skills and soft furnishings production.

The grant was to cover the salary for a full-time trainer/assessor for the

Soft Furnishings Scheme, plus expenses for a part-time paid

community service volunteer for this scheme, running costs, materials

and equipment. On the administrative training side, funding

covered the running costs of the scheme, the salary of a full-time

receptionist and the costs of her training. Both new schemes were to

offer the option of NVQ qualifications for participants.

Both schemes became operational in late February 1995, with the

opening of the Peter Bedford HA new facility at Stamford Works in the

London Borough of Hackney.

The Soft Furnishings Work Scheme

Participants received training to produce a wide range of high quality

soft furnishing items, including curtains, cushions, covers, tablecloths,

napkins, quilts and bed linens. Skills training included:

•

design and pattern making

•

use of tools and machinery

•

cutting, machining and finishing items to a suitable standard

•

use of different textiles and fabrics

•

team-working

•

time keeping and reliability

•

working to instructions and deadlines.

Training was delivered on site, by the workshop supervisor and

volunteer assistant. The emphasis was very much on the production of

high quality goods that could compete with others on the retail market.

Positive feedback from sales was found to be very important in

maintaining morale as well as in planning production. Good planning

of retail outlets and opportunities was vital for this purpose as well as

for bringing revenue into the scheme.

page 23

The scheme accommodated up to six participants a day, five days a

week. As part of the programme, the workshop supervisor became a

trained NVQ assessor, giving participants the opportunity to gain an

NVQ in Manufacturing Products from Textiles. Overall, around 20

people participated in the scheme, and by popular demand, three days

were designated ‘women only days’. The Soft Furnishings Scheme

proved popular beyond expectations: towards the end of the project

there were waiting lists to join the scheme on ‘women only days’.

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Mental Health Programme Report

“We get very positive feedback from participants in the Soft Furnishings

Scheme. The training there is of a very high standard. Overall, it is

one of our most successful work schemes ever.”

Project Leader, Peter Bedford Women’s Employment and

Training Schemes

‘It’s therapeutic. I'm not working at the moment - coming here gives

me something to do and somewhere to go. You learn new skills.’

Christine, attending just over a year

‘My social worker recommended Peter Bedford to me... I think Soft

Furnishings is brilliant - otherwise I’d be stuck indoors looking at four

bare walls. Being stuck indoors is like looking at paint dry. Being a

single bloke, there's more chance to make friends. I've made friends

here - before I didn't know anybody. Since I've been working here I've

got more confidence.’

Derek, attending 3 months

‘I like meeting people; I like doing the things I do like sewing and

making cushions and bags and sheets.’

Pamela, attending nearly 2 years

‘Before I came to the Soft Furnishings Work Scheme I'd go to day

centres. It's been a change in my life coming to the work scheme; I’ve

quietened down a lot. Money I've never had - the work scheme wages

help me to save up.’

Marian, attending for over a year

‘I feel fine here… I can pay for my holidays. I learn sewing here

Hilary told me that she could help me to be trained in sewing and get a

job.’

Anne Marie, attending 6 months

Positive feedback

What the

users thought

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FOUNDATION

The Administrative Training Work Scheme

The Administrative Training Scheme was set up to offer three

administrative training posts to women living in Peter Bedford

Housing. One was a full-time paid post based and managed within

the office administrative team at the Hackney site, and operated on a

one-year contract basis, such that each trainee could complete an NVQ

Level 2 in Business Administration during their term. Two further

part-time 'feeder' posts, based at Peter Bedford’s Legard Road site in

Islington, paid the post-holders allowances only as benefit

supplements. The feeder posts were designed to be less intensive,

offering women the experience to be able to make an informed choice

about whether they might want to take up the intensive post at the

Hackney site.

The full-time administrative worker had the support of Peter Bedford’s

employment worker who was also an NVQ assessor. The employment

worker provided individual on-the-job support and assistance with

applying for open employment to move on to when the one year

contract was coming to a close. Among the advantages of this post

was that it demonstrated the organisation’s ongoing commitment to full

participation by tenants in the running of the organisation, and

provided participants and enquirers with a first point of contact who

was particularly ‘user-friendly’ when they came to pay their rent or see

staff at the office.

The first post-holder successfully moved into open employment at the

end of her twelve-month contract. The second took up the post after

working on one of the ‘feeder posts’, and then completed eight months

of the one-year contract before moving on to paid employment outside

the organisation. The reception and administrative support services

they provided were of a high standard, and both gave very positive

feedback about their experience of the post.

Over the course of the scheme, the Peter Bedford HA office became a

City and Guilds accredited assessment centre for the delivery of the

Business Administration NVQ.

page 25

Project Successes

The Administrative Training Scheme was successful both in terms of

providing administrative support at the Peter Bedford Association’s

new Hackney site, and in enabling participants to go out and get

follow-on jobs. Similarly, the introduction of the Soft Furnishings Work

Scheme substantially increased the overall usage of work schemes by

women at Peter Bedford HA. Over 30 women were involved in the

two new schemes since start-up in February 1995, representing a third

of all the women participants at Peter Bedford HA. Targets for ethnic

minority participation were maintained amongst the new women: 20%

were from black or other ethnic minority groups, and 14% were Irish.

There were notable changes in the atmosphere at Peter Bedford HA

with the increased involvement of women, according to the Project

Leader. Staff noticed a positive impact on the organisation’s culture as

the environment became more welcoming. The new Soft Furnishings

Scheme made Peter Bedford HA a much friendlier place for both

women and men to come to.

Future Options

The Soft Furnishings Scheme has gone from strength to strength both

in terms of participant satisfaction and demand for places, hence the

scheme is something Peter Bedford HA would like to develop further.

Continued implementation of the NVQ training is also planned in both

the Business Administration and Soft Furnishings Work Schemes to the

point where people are gaining these qualifications on a steady basis.

Peter Bedford HA is expecting to improve the marketing of the goods

produced in the Soft Furnishings Scheme by changing the location of

their retail outlet. Suitable shop-front premises have been identified

and secured on a busy local high road. The income generated is

hoped to offset some of the costs of the scheme.

Cutbacks in the Peter Bedford Association’s core funding in 1996

necessitated considerable restructuring and operational down-sizing to

enable the organisations basic services to remain open. Further funds

are required to maintain staffing and management of the women’s

training schemes, and to expand these services to meet the demand

from participants. Both increased management capacity and support

functions would be needed to achieve these aims.

page 26

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FOUNDATION

page 27

Janet had been living long-term on an acute psychiatric ward. She

liked life on the ward and was very institutionalised and reluctant to

move out. The only time she had been discharged to an independent

living flat she had been re-admitted 24 hours later with acute alcohol

poisoning, having drunk one and a half bottles of spirits. It was felt she

was too much at risk to be discharged into an unsupported setting

again. In spite of her preference for living in the hospital her key work-

er was seeking a community placement for her due to increasing pres-

sure on acute beds, but was reluctant to push her out feeling that this

would lead to guaranteed failure. However, he could not find her a

suitable placement. Peter Bedford was suggested to her, and she came

to visit and reluctantly agreed to start a trial period in the Soft

Furnishings Work Scheme. The ultimate aim was for her to move into

Peter Bedford housing.

Janet would come with her worker from the ward initially for a

morning a week, her history of extreme distress in new situations

indicated that she would need a great deal of support to attend the

project, so it was planned for the worker to be around if Janet became

distressed, but not to actually come into the workshop with her.

Initially Janet could not spend more than 10 minutes in the workshop -

her distress included physical symptoms such as vomiting. The

expectation was that Janet would at some point refuse to come, and

there was concern around allowing Janet to undergo an experience she

found so distressing. But after attending a few times, she actively

wanted to continue, and all concerned decided to support her in this.

Gradually, over a period of months, Janet was able to spend longer

periods in the workshop. Her level of distress became manageable, then

finally disappeared altogether. She began to learn the skills needed to

produce things in the workshop, actively take part and enjoy the work.

Her motivation to move out of the hospital increased as a result. She

willingly moved into Peter Bedford housing six months after starting

her placement in Soft Furnishings. She now lives in Peter Bedford

housing and continues to attend the Soft Furnishings Scheme regularly.

Case study

page 28

Mental Health Programme Report

The Need to Improve Press Coverage of Mental Health Issues

B

y the early 1990s, service providers had begun to recognise that

users of mental health services were vital partners in developing

mental health provision to meet people’s needs. However, media atti-

tudes to those with mental health problems lagged far behind.

Emotive terms like ‘psycho’, ‘nutter’ or ‘lunatic’ were continuing to be

used by journalists on a daily basis in reporting on mental health

issues, feeding public ignorance and fear rather than encouraging

respect and understanding.

Even when journalists avoided sensationalism, the views of mental

health service users were largely ignored, or canvassed only to provide

personal testimony to add human interest to a story. Any serious

debate of mental health issues tended to be seen as a dialogue

between health professionals and politicians, ignoring the views of

service users both as experts in their own care needs - and as sources

of informed comment on the broader issues.

Lack of resources amongst mental health charities and user groups had

generally meant that they had no press officer or public

relations/media strategy - making it very difficult indeed to get the user

voice into newspapers running mental health stories. Since the media

had been shown to be a powerful influence on public attitudes to

mental health (see page 2), it was reasoned that funding targeted at

improving media coverage of the issues would be bound to improve

public attitudes somewhat towards those in mental distress.

Mental Health

Media Project:

Headlines,

Getting the

User Voice into

the Media

A new report, ‘Living in the Community’, on users’ experience of

community care, found that users thought the media was the single

most important source of stigma. Researcher Diana Rose said “mental

health organisations must work with the media, the most powerful

means of public education we have, to encourage more positive images

of mental health”.

Headlines, June 1996

Care-less community

Mental Health Programme Report

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CITY PAROCHIAL

FOUNDATION

The Headlines Project

The City Parochial Foundation granted MHM £101,776 over three years

to run a new initiative - the Headlines project.

The project brief was to redress the balance of press coverage of

mental health issues, by working closely with both journalists and user

led groups in the Greater London area. Funding covered the

appointment of a media relations officer with a specific remit to

promote users’ views and voices, and to develop a core group of

service users with good media skills to liaise with the press.

There were three key objectives:

•

to empower users through providing media-skills training and

back-up support to enable them to get their voice over in the

press; support elements to include the regular production of a

newsletter - ‘Headlines’ - reporting media successes and

campaigns and targeted at London-based user groups

•

to encourage responsible reporting of mental health issues, for

example by networking with professionals

•

to discourage irresponsible journalism, for example by

orchestrating co-ordinated campaigns of complaint.

The project commenced in August 1994, with the appointment of two

journalists job-sharing the media relations officer post. This

arrangement changed first in March 1996 when a new media relations

officer was appointed as sole post-holder, and again in December

1996, when the media relations officer left Headlines and a user

development worker was appointed for 3 days a week in his place.

For the final 8 months of the project, monies saved on the worker’s

salary were used to cover the costs of equipment and training involved

in starting to develop a user network on the Internet.

Empowering Users and Promoting the User View

The two media relations officers initially undertook considerable

development work, beginning with the recruitment of user groups to

participate in the project. Media skills training was developed, and a

system of ongoing support, advice and information exchange between

user groups and the Headlines workers was established.

page 29

Basic media skills training was run as a one-day workshop, designed

to provide the skills and support for maximising positive local press

coverage. Elements of the training included:

•

background information on how the press works and how to

work with them for maximum impact

•

planning a media strategy

•

interview skills training

•

writing a press release.

About 35 user groups in the Greater London area participated in the

basic training - and Headlines ran advanced workshops for groups

already active in media work who wanted to further improve their

press skills, for example in learning how to deal with journalists when

it came to more controversial issues, such as combating so-called

NIMBY (not in my back yard) campaigns against proposed mental

health facilities.

Once user groups were involved in press work, the Headlines media

relations officer would remain available for advice on getting a story

into the press - providing information on press contacts for specific

stories for example, and looking at press releases to see if there was a

better angle worth pursuing.

Other support services included the production of a user-written

leaflet, ‘You, the press and mental health’, the compilation of an

information pack on facts and figures surrounding mental health and

violence, and regular updates on the work of Headlines and its

associated network of user groups via the Headlines newsletter,

produced bi-monthly.

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Mental Health Programme Report

Two years ago when Headlines started there had been no formal

contact with local newspapers. A member of our group went on the

very first training day on writing press releases, and the skills learnt

there have been used ever since by the group. The training really

helped us focus on the importance of the media.

Most valuable has been the training in showing how to pitch a press

release. Whereas in the past we would have just picked up the ‘phone

to contact a newspaper, we now do a formal press release. It seems to

work, as the local paper does get back to us.

I think the media work with Headlines has helped the group to focus

on its image. Acquiring skills and confidence in dealing with the

media has affected the whole organisation. Members now know how

to send a formal press release, and nobody gives anything out to a

journalist on the ‘phone.

Group Leader, Bromley User Group

What the

users thought

Mental Health Programme Report

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CITY PAROCHIAL

FOUNDATION

Confronting Irresponsible Journalism

Headline’s brainchild, ‘Response’, was a letter writing campaign which

aimed to challenge negative reporting of mental health issues in the

press. Response had its first try-out in June 1995, when a letter to the

Independent sparked outrage in the mental health user movement. A

series of telephone calls galvanised user groups into rapid action. The

Independent received a flood of letters from psychiatrists, and groups

as diverse as Mind, the Manchester based Schizophrenia Media Agency

and local user groups. Several letters were published over the ensuing

few days - enough to keep the issue in the public eye.

In June 1996, the Press Complaints Commission (PCC) made its first

ever ruling against a newspaper for its use of offensive language in a

mental health story, following a barrage of complaints from service

users in the Response campaign. The press watchdog decided that the

Daily Star had broken Clause 15 of its code of practice by referring to

user, Paul Fahy, as a ‘raving nutter’ and a ‘loony’, after he kissed

Princess Di on the cheek on a visit to Liverpool. The reason for Fahy’s

mental distress, the death of his father, was buried in a tiny box at the

end of the five-page story.

Following the ruling, the Headlines’ Project Leader was fortunate

enough to be able to publicise the problem of press complaints and

mental health service users in an interview for Radio Four’s

programme, ‘Mediumwave’.

page 31

I have found Headlines’ advice and support to be excellent, and the

newsletter good and informative.

The work with Headlines has certainly flowed into other areas. For

example I learnt a great deal from the very first letter I did with [former

project leaders] Tim and Susannah, who altered the layout to make it

more effective. The culmination of this for me was the publication of a

recent letter of complaint I wrote as a member of Headlines’ Response

Group to the Daily Express over an article headed. ‘How years of

blunders have set free maniacs to butcher and rape the public’. My

letter to the Deputy Editor, Jean Carr, was used in its entirety.

Group Leader, The Consumer Forum, Hammersmith

What the

users thought

Networking with Professionals

Bridge-building with sympathetic journalists was relatively slow to

progress, though there were some successes. Not surprisingly,

Headlines found links with the broad-sheet newspapers and more

left-wing social issues magazines easier to establish than with the

tabloids - and the strategy of pursuing the best-chance outlets paid off.

Some journalists even began to approach Headlines for leads on

mental health stories.

In another important step in encouraging responsible reporting, the

NUJ Ethics Committee gave their agreement for Headlines to produce

new guidelines for journalists on reporting mental health issues. The

relaunch of a mental health press officers’ forum also helped in the

exchange of information and ideas.

User groups reported a number of successes in promoting positive

press coverage by working with members of the press. A leading

member of the Bromley User Group, for example, said she managed to

persuade a BBC radio journalist to take a different line of

questioning, moving away from questions based on an exclusively

medical view of mental health, after she had talked about the issues

from a user perspective, following advice from Headlines.

page 32

Mental Health Programme Report

Media work is very important in mental health. We are in receipt of

such bad press the majority of the time that it is necessary to work

constantly to redress the balance and re-educate the public not to

think of all mental patients as murderers!

We have worked very positively with our local paper, the Croydon

Advertiser, for example in a campaign for single-sex locked wards at

our local hospital, and more recently over the dire Mental Health Act

Commission report received by Warlingham Park Hospital. The furore

created by the Advertiser’s report resulted in the appointment of more

qualified staff for the hospital, a Mental Health Act worker and ward

clerks.

Problems remain in persuading the media to report positively on

mental health stories such as World Mental Health Day and the Defeat

Depression campaign. It is a question of keeping up the pressure.

We do hope this project continues and indeed expands to cover the

whole country. So many of us suffer mental health problems these days

that constant efforts must be made to do away with stigma thus

making it easier for community care to work. The community has to

be helped to care and the media is the foremost way to reach the

public at large.

Group Facilitator, Croydon Mental Health User Group

The experience of

one user group

Mental Health Programme Report

page 33

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Project Successes

The media skills training at Headlines significantly raised the skills

level of the user groups, so that they were much more confident in

dealing with the media and promoting the user view. Back-up

support from the Headlines Project was an important factor in their

success.

In terms of combating irresponsible journalism, the PCC decision on

the Fahy case was of national significance. There were other notable

successes. The appearance of black user consultant Les Bailey, on

Channel Four’s late-night discussion show, ‘Weekly Planet’, was

extremely powerful. His reasoned approach meant that he came over

as an expert on mental health in his own right - in direct contradiction

to the conventional media representation of mental health service

users - particularly black users - as mad, bad and dangerous.

Future Options

In the light of the successes of the Headlines project, MHM are

proposing to develop the work of Headlines into a national project

countering stigma - for which three years’ funding has been secured

from the Department of Health. This would employ two workers.

The first would be a media relations officer whose brief would be to

produce a newsletter for national distribution, maintain and develop

links with journalists and run a national press liaison service. The

second would be a user development worker, responsible for building

national connections with user groups and running Headlines’ media

skills training days. The setting-up of a novel project linking user

groups across the country via an Internet web site and mailing list will

be a key part of their brief.

I found Headlines’ media skills training particularly useful in

understanding how journalists operate, as well as the pressures they

are under. It has also helped in dealing with calls from TV people, and

in understanding the tight deadlines they have to work to.

There has been a knock-on effect in terms of giving MDF members who

went on the course more confidence and support in dealing with the

press. It has been very empowering.

Group Leader, Manic Depression Fellowship, Greater London

The benefits

of training

Mental Health Programme Report

page 34

The Need for a Mental Health User Group in Croydon

I

n 1992, the London Borough of Croydon and Croydon Health

Commissioning Agency produced a strategy document outlining the

proposed development of mental health services locally

12

. The report

assessed the prevalence of mental health problems in the region,

suggesting that mental distress affected up to a third of people in the

local community, but that only around 10% were in touch with the

mental health services. Much larger numbers experiencing mental

health problems went undetected. The figures suggested were:

•

mental distress in the community

80,000-100,000

•

mental distress among GP attenders

73,000

•

mental disorders recognised by GPs

32,000

•

mental disorders treated by the mental health services 6,000

•

annual admission to hospital

1,000

The report also highlighted the need for user involvement in the

planning and evaluation of local mental health services, previously

called for nationally in the Health of the Nation White Paper and

Patient’s Charter.

The driving force behind CMHUG derived from the anger of a number

of service users at the way in which services were organised without

regard to users’ views. The evolution of the group began when the

local Mind association nominated one of its staff members responsible

for developing user involvement in planning. As early as January 1992,

there were meetings with service users to see how user involvement

and advocacy could be developed. The first Users’ Forum was

convened in May 1992 at Warlingham Park, the local psychiatric

hospital, from which a steering group emerged to take forward the

development of a Patients’ Council. From the Patients’ Council,

interest grew in other aspects of mental health services locally. The

linking of these different groups and individuals led to the formation of

CMHUG.

CMHUG received its first funding from local Joint Finance, which

allowed it to set up it own office. Even then, much of the group’s time

was spent struggling for resources rather than on substantive work. It

was felt that the best way to address the need of enabling user

involvement in Croydon would be to consolidate and expand the

group, and that this would require further funds that were not available

locally.

12

London Borough of Croydon and Croydon Health Commissioning Agency (1992). Strategy for

mental health service development 1993/4-1996/7.

Croydon Mental

Health User

Group:

Campaigning

for Better

Mental Health

in Croydon

Mental Health Programme Report

page 35

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The CMHUG Project

The City Parochial Foundation granted CMHUG £91,504 over three

years to open its office full time, with a paid administrator. This would

allow the group to respond more readily to calls for help and user

input. At CMHUG’s request, the grant money was to be paid to

Croydon Mind who would take on the role of employer for the

administrator, administer the finances and take part in the steering

committee.

The funding would allow CMHUG to:

•

develop and expand its involvement in shaping local mental

health services via membership of steering groups, working

parties, joint planning and strategy reviews, and participation in

staff recruitment

•

develop its campaigning work on mental health issues

•

continue to facilitate the Users’ Forum and Patients’ Council

•

provide ‘therapeutic earnings’ of up to £15 a week (as allowed by

social services) to volunteer workers who would otherwise be

unemployed

•

purchase computer equipment and other office equipment

•

develop its publicity via leaflets, posters and a regular newsletter

‘Talking Treatment’

•

undertake public awareness-raising campaigns

•

expand its liaison work with other user groups

•

develop and enhance skills within the group, such as advocacy

and administration skills

•

provide training to mental health workers on user issues.

Vision and Values

CMHUG believed that users should be at the centre of mental health

services planning, and that anger about existing services should be

channelled constructively. When consulting or advising, CMHUG

never used a criticism-only approach, instead giving credit where it

was due, as well as offering positive ideas for change. CMHUG was

not separatist, but saw a need to work in partnership with health and

social services in order to effect change. The group’s efforts to make

allies paid off, ensuring that local senior management supported

CMHUG from the beginning.

Mental Health Programme Report

page 36

How CMHUG Worked

CMHUG was involved in almost every aspect of mental health services

in Croydon. For example, to ensure effective user participation in

planning services at least two or three CMHUG representatives

attended all planning meetings on mental health. Projects CMHUG

was involved with included:

•

The Croydon Mental Health Service Reprovision Programme

•

The Mental Health Policy Development Group for the Croydon

Community Care Plan

•

The Farleigh Unit Review at Warlingham Park Hospital

•

The Section 117 Aftercare Planning Group

•

The development of user groups in mental health resource

centres borough-wide

•

The development of Croydon Young People’s Centre

•

The Safe House Project Group

•

The Section 136 (Police Powers) Place of Safety Policy

Development Group

•

The Welfare Benefits Working Group.

CMHUG was also involved in monitoring both social services and

mental healthcare provision, commissioned by Croydon Social Services

and the Community Health Council, respectively.

CMHUG had a strong campaigning arm, which aimed to promote

mental health, public awareness of mental health issues, and

understanding of the user perspective amongst mental health service

workers. CMHUG ran stalls and floats on a number of public

occasions, including the Croydon Carnival and World Mental Health

Days. They were also involved in setting up a London-wide user

forum as a resource for mental health service user groups in the

capital, together with Good Practices in Mental Health, the UK

Advocacy Network (UKAN) and the UK Federation of Small Mental

Health Agencies.

CMHUG also provided a support and information service for individual

service users, which they saw as a key part of their work. They

received, on average, between one and three calls a day from people

in distress requiring support. There was considerable two-way traffic

between the CMHUG steering group and its wider membership, with

CMHUG being able to canvass views on the needs of mental health

service users via their members, and feed these back to the authorities

formally via reports, committees and working groups.

Mental Health Programme Report

page 37

Operating Style

Internally, CMHUG avoided hierarchies, and planned by consensus as

a team. They set formal objectives and worked to them until their

aims were achieved. They avoided long-term plans, sensing that these

could lead to a shift away from their consensus approach. In their

view, avoiding long-term plans also allowed them to be instantly

reactive to local circumstances.

The group was aware that its lack of formal structure could make it

difficult for others to understand how CMHUG worked and how they

could work with them. However, CMHUG was firmly of the view that

their lack of structure was not an issue for them, but only for others.

CMHUG's view was that hierarchy could be destructive in user groups,

and they felt that their achievements demonstrated the effectiveness of

their democratic approach.

The group’s paid administrator was employed by MIND. The rest of

the work was done on a voluntary basis by members, and all

information in the office was open to everyone. There was only one

written policy, on equal opportunities. However, group members

acknowledged that there were unwritten rules: members did not

disagree with each other in public, for example, and did not make

reference to personal experiences in planning meetings.

Project Successes

When the City Parochial Foundation awarded its grant in 1994,

CMHUG had six members and an office staffed by volunteers three

mornings a week. By December 1996, there were 235 members, two

adjoining offices staffed five days a week, two phones, two computers

and a part-time member of staff. The funding allowed CMHUG to

campaign effectively, put across the user viewpoint, and gain respect

for its work. At the same time, the funders always supported CMHUG

in the direction the group wanted to go, in particular, backing its

increasing emphasis on public awareness raising.

The volume of work undertaken by the group was tremendous, with

the result that CMHUG had a major impact on mental health services

locally. Some notable successes have included:

•

production of a video on young people’s mental health (a

second video, on self-harm, was begun)

•

production of a training pack on promoting young peoples’

mental health aimed at schools, colleges and youth clubs

•

reversion to single-sex wards at a local psychiatric hospital, after

an independent evaluation of mixed sex wards commissioned by

CMHUG

•

research into users’ needs for mental health crisis services (results

available 1997)

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Mental Health Programme Report

page 38

•

provision of awareness training sessions for nurses, occupational

therapists and GPs

•

successfully campaigning, along with Mind in Croydon and the

Community Mental Health Council, for Croydon Health to

become part of the Bethlem and Maudsley Group Mental Health

Trust

•

assistance with the NHS clinical audit of mental health services in

Croydon

•

open days held twice a year for members and prospective

members

•

public awareness raising work on World Mental Health Day and

for the Defeat Depression Campaign.

My three ‘holidays’ in Croydon's local psychiatric institution were as

enlightening as they were horrifying. I could not conceive that such

degradation and inhuman treatment were possible in what passes for a

civilised society.

I have to say I was treated very well, possibly because I am white,

middle-class, middle-aged and fairly articulate, but what I saw happen

around me made me determined to try for change. How psychiatry can

justify its existence when basically it has not changed much in 200

years beats me entirely. A Parliamentary Select Committee in 1815

advised that aggressive and depressive patients should not be mixed.

This still happens in 1996 so what have we learned?

I made three very good friends in my time at Warlingham Park

Hospital, and this saw the origins of the Croydon Mental Health Users'

Group, thanks to help and encouragement from Mind in Croydon. We

now have nearly 250 members and a reputation for a positive and

constructive contribution to the improvement of mental health services

locally.

Government has to realise its responsibility to persuade every citizen of

the benefits of good mental health. Life can be a nightmare these days,

especially for the young, and we need a national mental health

promotion campaign to address some of these difficult issues. Mental

health has to be dragged out of the closet and discussed. So my brain

works differently from yours, so what? Ninety per cent of the time I can

still make a useful contribution to the world at large!

Social psychiatry has definitely been kicked into touch by the experts so

let's have a bit of common sense in all this! The majority of us break

down for social reasons and need practical help to pick up the pieces.

CMHUG Founder Member

Case study

Mental Health Programme Report

page 39

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Future Work

CMHUG would like to develop its outreach to people in mental

distress and continue its educational and mental health promotion

drives, particularly in schools. Though awareness raising work is

difficult to monitor, CMHUG has noted that people still feel very

uneasy talking about mental health issues. Hence members are also

keen to expand this area of work.

Given CMHUG’s notable achievements to date, it seems likely that the

group will continue to make the voice of service users heard both

locally and on a wider scale.

“The Users' Group not only focuses minds on the needs of people with

mental health problems, but also provides a type of occupational

therapy for those who join and support it”.

CMHUG member

“CMHUG provides support to many people, both friends and strangers.

This can lead to pressure, and times of difficulty, as well as success and

comradeship. It is a credit to the group's strength that it can both sup-

port and inform”.

CMHUG Support & Development Worker

Why user groups

are important

Mental Health Programme Report

page 40

The Need for a Somali Mental Health Project

I

n the early 1990s, the needs of the Somali community in Tower

Hamlets (an estimated 12,000 people) were acute. There were

exceptionally high rates of unemployment, illiteracy and poor housing.

Many Somalis were refugees who faced complex practical, legal and

psychological issues - including problems arising from language

barriers, immigration issues, and difficulties with benefits claims. Many

were also severely distressed as a result of the civil war in their

homeland and the traumas of being uprooted and separated from their

families and friends, as well as being isolated in Britain.

At the end of 1992, the Black and Ethnic Communities Advisory

Committee of Mind in Tower Hamlets commissioned the London

School of Economics Community and Health Research Group to carry

out a study of mental health needs amongst the main ethnic

communities in Tower Hamlets. Their report made a special plea on

behalf of the Somali community, and the main recommendations of

this report were incorporated into a funding proposal submitted to the

City Parochial Foundation.

The Project

The City Parochial Foundation granted Mind in Tower Hamlets

£175,118 over three years to set up a specialist Somali mental health

project, focusing on the 16-30 age group. The overall aim was to

improve the mental health of Somalis in the London Borough of Tower

Hamlets through early intervention and liaison.

The funding paid for the recruitment, training and employment of two

full-time Somali workers - a man and a woman, and provided a

development budget for the running of social drop-in sessions, outings

and other activities suggested by the users.

The initial targets for the project were:

•

to provide an information and advice service for users and mental

health workers

•

to offer intensive support and advocacy to individual clients

•

to set up a number of drop-in and living skills groups

•

to produce and distribute mental health information leaflets in

Somali and in English

•

to organise training workshops for workers on issues affecting

the mental health of the Somali community.

Daryeelka

Maanka: Mind

in Tower

Hamlets’ Mental

Health Service

for the Somali

Community

Mental Health Programme Report

page 41

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How Daryeelka Maanka Worked

The Project commenced its operations in July 1994 with the

appointment of two workers to the preventative team funded by the

City Parochial Foundation. A third Somali worker, funded through

Mental Illness Specific Grant (MISG), focused on Somalis with

long-term mental health problems. All three workers were supervised

by Mind’s Support Services Manager, with advisory input from a

specially convened Somali mental health steering group.

Intensive support to individuals and advocacy took most of the

workers’ time. This ranged from help with practical issues raised by

language barriers, to complex immigration and benefits issues and

intensive emotional support. The outreach work also involved

providing support to Somali people in the local psychiatric hospital,

and street work with homeless people and persistent street drinkers in

the Whitechapel area.

The workers ran several group sessions for the Somali community: a

weekly all-day women’s therapy group, a women’s woodwork group,

a media skills group, and a luncheon group. The groups were

organised in such a way as to be congruent with Somali values and

experience and acceptable to people who were not used to using

mental health services. The women's group, for example, had health

and fitness sessions and Somali dancing, and provided both collective

and individual counselling opportunities. The groups were well

received by the local Somali community: members seemed to value

greatly the experience of having a safe and mutually supportive space

in which to express things that would traditionally be kept private.

The information and advisory service initially attracted an average of

160 phone calls a week, of which roughly 100 were from members of

the public and 60 were from professionals. The volume of calls

decreased somewhat in the third year of the project, since other Somali

workers had been employed to deal with legal issues and welfare

rights in the borough.

The project workers provided health awareness sessions to Somali

students, and training to health and social care professionals on Somali

mental health issues. In addition, representatives from the project

attended a number of planning groups working to develop local

services for the Somali community.

Mental Health Programme Report

page 42

Who Used the Service?

Two-thirds of Somalis who used Daryeelka Maanka were men: in

1995-96, for example, there were 145 men to 62 women. Over 50% of

those using the Project were under 30 years old. Over 40% were not

in stable accommodation, often living on a temporary basis with family

and friends, whilst over 30% lived alone.

The vast majority of the Project’s users (over 80%) had no previous

contact with the statutory mental health services. This was probably

indicative partly of the low awareness of professional mental health

services amongst members of the Somali community and partly of the

stigmatisation of mental health problems and hence mental health

services in Somali culture. The majority of the Project’s users found

out about Daryeelka Maanka through community networks; around

48% were self-referrals, some of whom may have originally been

referred by their families.

Project Successes

In terms of providing information and advice, Daryeelka Maanka

exceeded its targets. The original target was to provide for 500 people

per annum: in the first two years, the project received calls from an

average of 125 people per week. In addition to information sheets and

leaflets, the project produced a quarterly newsletter for the Somali

community from early 1996. In terms of intensive individual support, it

provided twice the original target amount. The group sessions were

likewise very popular and well attended, which was particularly

encouraging in the case of the women’s groups; Somali women on the

whole are traditionally much more difficult to engage with mental

health services.

One of the great successes of the project was that people from the

Somali community were increasingly willing to come forward and seek

help. Thus a need for raising awareness of mental health issues within

the community was met by the project, along with many of the mental

health needs of individuals. Daryeelka Maanka developed to a stage

where its staff were also working effectively with the statutory mental

health services, providing an essential bridge for the Somali

community. The support of the workers to community members with

severe mental health problems was provided in close liaison with the

community mental health teams and their statutory key workers.

Mental Health Programme Report

page 43

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Future Work

Now that there are other Somali workers in Tower Hamlets, Daryeelka

Maanka will continue with two project workers instead of three. There

is scope to run more women’s groups, to develop the men’s work, and

to strengthen effective co-working with the statutory services and their

community mental health teams. Overall, Mind in Tower Hamlets feel

that it has evolved a good combination of services for the Somali

community with Daryeelka Maanka, and would like to continue with

the project in order to meet now identified mental health needs within

the community.

Magood is a women in her mid-thirties. She is married and has four

small children, the oldest being five years. She looks after the children

adequately when she is not too depressed. She is not known to the

locality CMHT (Community Mental Health Team) and rarely visits her

GP. She is, however, extremely depressed. She is confused and isolated,

does not read or write, and apparently does not want to improve her

situation through education.

Her husband chews khat, but he refuses any help. He causes Magood a

lot of problems. He hits her because she does not seem to be interested

in the world. He blames her for everything that goes wrong.

Magood first came to Daryeelka Maanka in March 1996 for help with

letters. She hardly discloses anything, even though she knows that the

project worker is a mental health worker and she brings her personal

letters to read. She now attends the woodwork group regularly and

sometimes comes to the lunch club. Her children come with her to

Open House and play with the toys in the creche; at home they have no

toys or television. Woodwork and the creche are quite important for

Magood’s survival. Some evenings she does not do any woodwork, but

just sits and listens to the other women.

Daryeelka Maanka are providing Magood with on-going support.

Case study

Mental Health Programme Report

page 44

Jama Osman came to Britain in 1989, suffering from severe injuries

from gunfire. During the civil war he had witnessed corruption,

looting, false imprisonment, soldiers raping women. He took part in an

uprising, and was caught and tortured, but escaped. In later

fighting he was hit in the back of the head by a bullet which came out

of his mouth, destroying his palate. He escaped to Britain for medical

attention, and had two major operations. When the treatment was

completed he was discharged and allocated a flat on the seventh floor

of a block. He spoke little English, was worried about relatives in

refugee camps and caught up in the civil war, and he was isolated. He

became lonely and frustrated. He began to want to go back to

Somalia, despite all its dangers.

He approached Daryeelka Maanka in February 1995. He was having

flashbacks of traumatic events, including scenes of family members

being killed in front of him. He had financial difficulties. He was

chewing khat six nights a week, leaving him lethargic and

demotivated each day. His large family, fifteen brothers and ten

sisters, were mostly spread around refugee camps in East Africa. Letters

from them asking for financial help added to his worries. As the only

member of the family living outside of East Africa, he was perceived as

being rich. Every letter he received to which he was unable to respond

added to his depression.

The Daryeelka Maanka project worker, Abdirashid, helped him to

obtain disability benefits. They were back-dated, so Jama Osman was

able to send some money to his family, which made him happier.

Abdirashid also helped him to obtain a travel permit.

Through this period Abdirashid was concerned about Jama Osman's

mental health, and was eventually able to accompany him to his GP,

who referred him to a consultant psychiatrist. The psychiatrist referred

him to the locality Community Mental Health Team. He was

diagnosed as suffering from post traumatic stress disorder. Through

the project Jama Osman is now getting computer training and

attending the Somali lunch club at Open House. Gradually he has

become more confident. Abdirashid is now trying to get him

re-housed.

Case study

Mental Health Programme Report

page 45

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M

any valuable lessons were learnt during the course of the Mental

Health Programme, both by project workers and managers, and

by the funders. Since many of the themes that emerged recurred

across projects, they are documented collectively here, rather than in

the reports of individual projects. Key points that emerged can be

summarised as follows.

•

Management needs to be very flexible and supportive if small-

scale voluntary and user-run projects such as these are to

succeed. Both refugee and advocacy groups work in different

ways from professional health and social care services, and

professionals need to appreciate the differences.

•

Outreach to black and minority ethnic groups from largely white

organisations can be hampered by cultural and ethnic differences

and by racism, and tends to be most successful when efforts are

made to engage these groups on their terms.

•

Refugee mental health projects are a completely new area and, as

such, offer a particular challenge above and beyond the

development of a service.

•

In operating a mental health service for refugee communities,

flexibility is essential in terms of the type of services offered and

the way they are run if they are to engage members of the

community they are intended to reach. Counselling services in

particular often need to be complementary to providing practical

care. A holistic approach will be the norm rather than the

exception.

•

Appropriate counselling and mental health support skills exist

within refugee communities, and can be effectively engaged in

serving those communities if recruitment strategies are carefully

planned.

•

Countering the stigma associated with mental health problems is

a key part of the work of any voluntary agency. The importance

of awareness-raising work should not be underestimated in this

regard.

•

There is a vital role for funders and purchasers in supporting the

growth and development of small voluntary and user-led projects,

and thereby expanding choice for users and potential users of

services in their constituencies.

•

Consistency of staffing in advocacy and refugee projects such as

these is essential in order to enable the work to become

established.

•

Funders need to allow adequate time for the development of new

projects, and funding contracts should not restrict this important

work. A five-year funding period may be more appropriate than

three years in allowing sufficient time for such projects to set up

and establish themselves.

Lessons for the

Future

Mental Health Programme Report

page 46

Outreach to Black and Minority Ethnic Communities

A priority for the projects was to develop means of reaching out to

black and minority ethnic peoples in Greater London. For largely

white groups, there appear to be three key blocks to significant

progress in this work.

•

Racism and the oppression of labelling. There is substantial

evidence to indicate that most black users have negative

experiences of using mental health services. Research by Mind

and other bodies reveals extensive institutional racism within the

services.

•

Lack of cultural accessibility. Cultural and language differences

can mean that fundamental concepts of mental illness -

symptoms, causes, forms of treatment - do not translate easily,

and that the Western medical model of mental illness alienates

people in some communities.

•

Stigma and community exclusivity. Mental illness in any form is

highly stigmatised and therefore mostly unacknowledged

amongst particular minority groups, for example, the Chinese,

and many African communities. Coupled with this is an

established trend for support groups to remain based within and

exclusive to particular communities.

Both the Manic Depression Fellowship (MDF) and Mental Health

Media experienced initial difficulties in making contact with black and

minority ethnic service users. In addition to the major obstacles

identified above, indicators from the MDF Greater London Project

suggested a particular reluctance amongst black people to

acknowledge or accept the label ‘manic depression’ in addition to that

of service user. Yet acceptance of the condition (‘ownership of’) is the

key motivation for self-help group participation. To find a way of

developing this work, MDF employed a black outreach worker to

conduct a piece of action research involving MDF contacts in Waltham

Forest and Hackney, two London boroughs with high ethnic minority

populations. A report of the findings is currently in preparation.

In the case of the Headlines project at Mental Health Media, initial

difficulties in establishing links with black user groups were felt to be

due in part to the fact that there are fewer user-led black groups in

operation. With persistence though, Headlines eventually made links

with three projects. This was achieved through contact with Tower

Hamlets Mind, during discussions about holding an event on the sub-

ject of black users and the media; through a new Forum for African-

Caribbean Users, supported by Good Practices in Mental Health, for

which Headlines helped to secure coverage in ‘The Voice’; and finally

through the Islington based ‘Lambo’ African and Caribbean Centre, in

training members and providing press support for World Mental Health

Day.

Mental Health Programme Report

page 47

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Refugee Issues

Nafsiyat and Daryeelka Maanka, the Somali mental health project at

Mind in Tower Hamlets, highlighted a number of common issues that

are likely to arise in future mental health work with refugee

communities. These were as follows.

•

Concepts of mental health and illness are frequently alien to

these communities.

•

Mental illness is often highly stigmatised. This was a particular

problem amongst the Somali community in Tower Hamlets,

where signs of mental distress are seen as weakness.

•

The concept of counselling is often unfamiliar. In their home

country individuals are much more likely to talk to a friend or

relative, and the idea of discussing personal issues with a stranger

can seem very odd. Cultural barriers will also often discourage

people from accessing such a service. Counselling is unheard of

in the Somali culture: one is not supposed to express emotion,

thus many Somalis in distress tend to display physical symptoms

instead.

In light of these factors, Daryeelka Maanka had to be extremely

flexible in its approach, providing more than just a mental health

service. Groups, for example, were organised around fitness or skills

training, whilst one-to-one work was operated within very flexible

boundaries in order to gain the trust and confidence of members of the

community it was designed to serve. The drawback with this

approach was that the project workers could be very overstretched by

demand. However, it did demonstrate a need for better understanding

of mental health status in the Somali community.

The Nafsiyat refugee project encountered many of the same issues in

their work with children and young people. A number of observations

were made as to what was required for successful work with young

refugees. These were as follows.

•

Therapy services offered to a sibling along with a client or to a

small family group can improve take up of the service by young

refugees.

•

Boundaries need to be defined in working within school and

college settings; agreements on what children are told as to the

limits of confidentiality should be made in advance with the

school and clearly stated to the children.

•

Evaluating group work with young children demands a different

approach from the usual; children aged 12 -14 have difficulty in

completing a written evaluation form - so to ensure that

evaluation takes place, a one-off evaluative discussion session is

recommended at the end of a group work series.

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A particularly encouraging finding from the Nafsiyat project was the

relative ease with which volunteer trainee counsellors were recruited.

The project co-ordinator was repeatedly told that it would be a difficult

undertaking to recruit sufficient volunteers with appropriate skills from

the refugee communities. In fact, there were more suitable applicants

than places available on the first training course, and all those recruited

had some background in counselling training prior to starting the

course. On the down side, it did take the project longer than

anticipated to recruit the volunteers. The message Nafsiyat would

wish to share is that health and social care agencies need to think

carefully about their recruitment strategies and whether they are

presenting information in places where members of refugee

communities are likely to see it and respond. A proactive approach is

required.

Management Issues

All-round flexibility on the part of managers and purchasers is essential

in order to ensure the workability of small-scale voluntary and user-led

projects. Management can help to support the development of such

groups, but cannot and should not insist on their complying with the

standards of planning, assessment and presentation of well established

organisations as they develop.

Key management issues in the projects have included:

•

lack of monitoring and evaluation

•

difficulties in setting realistic or clear objectives

•

lack of a professional management structure and ethos, as well as

a lack of understanding of the organisational systems governing

the care network in which they operate.

Monitoring and evaluation

Lack of monitoring and evaluation was an issue for the majority of

projects, and is of particular concern since it can affect the ability of

such projects to secure continued funding. This is in some part due to

the frequently pragmatic and informal structure of small voluntary and

user-led advocacy projects, together with their emphasis on service

development rather than provision. The City Parochial Foundation

supported all groups in developing systems by setting up two joint

workshops on monitoring and evaluation, and by providing a

consultant who visited all the groups individually to help them develop

their own systems.

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Resistance to complying with provider requirements on monitoring can

also mean that such groups are unable to provide the materials

specified by funders as part of a funding agreement. The Croydon

Mental Health User Group, for example, operated a policy of not

asking any details about new members personal lives, a practice

developed in response to members’ previous experience in having to

relate the same information to mental health professionals repeatedly

as they were going through the system. Thus they were not able to

show who used their service in terms of mental illness diagnoses, a

common requirement now that health policy stresses the need for

targeting people with severe mental illness. CMHUG did not want to

operate in a way that resembled statutory services - and their strategy

was not to compromise on this issue. CMHUG would acknowledge

that they have been unusually lucky in their funders who have worked

with them in a way that has empowered them to create their own

approaches

Learning the system

Lack of understanding of the procedures, laws and unwritten rules

governing the system(s) in which they operated was problematic for

many projects. For MDF and CMHUG, establishing good links with

Health and Social Services providers helped to foster mutual

understanding and support the groups’ acceptance and development.

For Mental Health Media, providing training in media skills to advocacy

projects helped to promote understanding of how journalists operated

and the pressures they were under, and thus facilitate effective use of

the media by these groups.

For the refugee projects, the workers also needed to learn the systems

governing the communities which they were serving - and to act as a

bridge between these and the systems used by the mental health

professionals they came into contact with. Operation of the Somali

mental health project, in this regard, was associated with a raft of

cultural and management issues which required a great deal of

flexibility on the part of both management and workers to resolve. The

white professional ethos simply did not apply to the way the project

needed to be run, either in terms of working styles, time management,

or boundaries and confidentiality. There was also the issue that the

workers could become isolated, being managed by a white person in a

non-Somali organisation. Moreover, supervision and monitoring are

alien to Somali culture and have sometimes felt to the workers like a

lack of trust. Realising this, Mind offered external supervision by

Somali supervisors to project workers, and this was well taken up.

Regular supervision sessions and close yet flexible management led to

a growing appreciation of the difficulties on both sides.

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The working style of the Somali mental health project was markedly

different from that of statutory services in that the approach taken to

the mental health needs of Somalis by the project workers was a

holistic one. They did not operate boundaries between mental health

and practical problems, but would undertake advocacy and counselling

with an individual, as well as providing practical support with the tasks

of daily life and immigration applications. Their flexibility extended to

the hours project workers were available, the people they worked with

(they were not able to restrict their work to the 16-39 age group), and

where they worked. Needless to say, workers in the statutory services

could often find this approach baffling and fail to understand the

varied roles of the project workers. This necessitated a lot of

awareness-raising work amongst statutory and voluntary services

workers which was helpful in building bridges between the Somali

community and the professionals.

Objective setting

Setting realistic objectives was problematic for two of the projects in

different ways. First, MDF initially set an objective of three new

self-help groups in each of 33 London boroughs over three years.

Within the first eight months, however, this was recognised to be

unrealistic, and the targets were revised by agreement with the

funders.

Second, Peter Bedford HA severely underestimated the time needed to

set up as an NVQ assessment centre for both of its women’s

employment and training schemes. For the administrative training

scheme, where NVQ training was an integral part of the post, this had

an adverse effect on the project schedule. That this happened was not

entirely surprising: there are few mental health employment schemes

that offer participants the opportunity to gain NVQs, thus the Peter

Bedford Organisation did not have a body of knowledge and

experience to draw on in their planning. Implementation of NVQs is

a long process requiring provision of NVQ induction training for the

trainer/assessor, the development of policies, procedures and practices

in line with the standards, and the initial piloting of the NVQ training

scheme with one or two participants to enable the trainer to gain their

assessor qualification. A further issue is that for any NVQ training

centre, individual students have different needs. Peter Bedford HA

accordingly found that their trainees required considerably different

degrees of support and widely varying timetables for achieving

successive stages of their NVQ. These factors need to be taken into

account by agencies planning to implement NVQs for their users, since

they can mean that timetables and work schedules slip considerably

from those originally planned.

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Implementing NVQ training nevertheless had many benefits for the

Peter Bedford Housing Association, in terms of developing

management systems for a productive and competent workplace,

guiding the identification of training needs for individuals, and giving

participants the opportunity to gain a qualification. Based on their

experiences of setting up the NVQ in Business Administration, the

process ran much more smoothly second time around.

Countering stigma

Stigmatisation of mental illness remains an enduring problem, creating

a barrier to normal life in the community for mental health service

users, and forming a backdrop for all the mental health work of the

projects in this programme.

Different projects have had different approaches to dealing with

stigma. At Peter Bedford HA, the emphasis is on empowerment, and

involving the participants in every aspect of the work. MDF are very

open about their work, promoting a network of support groups to

create a sense of solidarity and lessen the isolation of sufferers. The

Somali refugee project chose to play down the mental health aspects of

their work in order to attract people to the project who might

otherwise not have felt able to attend. Mental Health Media and

CMHUG both took a direct approach to countering stigma and raising

public awareness about mental health issues.

Stigma for service users is closely linked to media coverage of mental

illness and mental health issues. The media consistently fail to reflect

the true facts that:

•

mental distress is a poor predictor of violent behaviour

•

the number of murders committed by people with mental illness

is very small - and has remained steady for approaching 40 years,

whilst the number committed by the rest of the population has

more than doubled

•

people with mental distress are far more likely to harm

themselves than other people.

In this climate, misleading reports of mental health issues are the norm,

rather than the exception. The Confidential Inquiry into Homicides

and Suicides by Mentally Ill People

13

found 34 cases of homicide

committed over a three-year period by people who had been in

13

Confidential Inquiry (1996). Report of the Confidential Inquiry into homicides and suicides by

mentally ill people, London, Royal College of Psychiatry.

Mental Health Programme Report

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contact with psychiatric services within the previous year. Of the 22

cases which could be followed up in detail, the Inquiry found that only

two were random killings by strangers, only half had been in

psychiatric hospital at all that year, and none had been discharged

from a long-stay institution into the community. Nevertheless,

subsequent reports of this research in the press were fairly uniformly

inflammatory. ‘Sick and dangerous’, ran the headline in the Daily Mail;

‘Mad policy’, said the Daily Star; and ‘Free to Kill’, said the Sun. In

fact, only about six of this country’s 700 killings each year (less than

1%) are committed by people who have been in psychiatric hospital in

the previous year.

Mental Health Media have made good headway in supporting local

groups to counter the barrage of negative media coverage and

establish increasingly strong media profiles that were listened to by the

local press.

CMHUG likewise ran a number of awareness-raising events to reach

the public directly, and promote an alternative image of mental health

service users as capable individuals taking charge of their lives.

Conclusions

Small-scale voluntary and user-led projects offer the potential for

user-friendly, user-orientated services that are less formal and less

stigmatising than statutory mental health services, and can provide a

true alternative to the health and social care that is framed by the

traditional medical approach. Such projects often represent the

cutting-edge of a needs-led service and, as such, can give a lead to

service development on the ground, as well as providing a grass-roots

influence on statutory services planning.

Lack of resources, however, can make such alternative services

extremely vulnerable. Limited funding can often mean that they

depend on one or two key individuals whose input is crucial to their

continued success. Difficulties in acquiring ongoing funding can be

repeatedly encountered, particularly when groups are unfamiliar with

the language and operational procedures of potential funders. Flexible

and supportive management is required on the part of managers and

purchasers if such services are to survive as an integral part of the

network of community care.

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MANIC DEPRESSION FELLOWSHIP: Expanding the MDF

Self-Help Network in Greater London

Project leader: Karen Campbell

CPF grant: £132,732 over three years

Further information from: Karen Campbell, Greater London

Director, Manic Depression Fellowship, 8-10 High Street,

Kingston-upon-Thames, Surrey KT1 1EY. Tel: 0181 546 0323

NAFSIYAT: Therapeutic Work with Young Refugees

Project leader: Gita Patel

CPF grant: £148,766 over three years

Further information from: Gita Patel, Nafsiyat Intercultural

Therapy Centre, 278 Seven Sisters Road, Finsbury Park,

London N4 2HY. Tel: 0171 263 4130

PETER BEDFORD HOUSING ASSOCIATION: Creating

Employment and Training Opportunities for Women

Project leader: Brian Dawn

CPF grant: £159,066 over three years

Further information from: Brian Dawn, Peter Bedford Housing

Association Limited, Legard Works, Legard Road,

London N5 1DE. Tel: 0171 226 6074

MENTAL HEALTH MEDIA: Headlines: Getting the User Voice into

the Media

Project manager:Radhika Bynon

CPF grant: £101,776 over three years

Further information from: Radhika Bynon, Mental Health Media,

The Resource Centre, 356 Holloway Road, London N7 6PA.

Tel: 0171 700 8131

CROYDON MENTAL HEALTH USER GROUP: Campaigning for

Better Mental Health in Croydon

Project leader: Jane Field

CPF grant: £91,504 over three years

Further information from: Jane Field, Croydon Mental Health

User Group Steering Committee, Cornerstone House, 14 Willis

Road, Croydon CR0 2XX. Tel: 0181 665 0210

DARYEELKA MAANKA: A Mind-Led Mental Health Service for the

Somali Community in Tower Hamlets

Project leader: Val Ford

CPF grant: £175,118 over three years

Further information from: Val Ford, Support Services Manager,

Mind in Tower Hamlets, 13 Whitethorn Street, London E3 4DA.

Tel: 0171 537 7284

Project Details

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