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    Tuesday morning was the launch of the Resolution Foundation report, Healthy finances? Options for funding an NHS spending increase – a response to the rumoured government “birthday present” for the NHS as it turns 70 on 5 July 2018.

    The audience included party advisers (I spotted a Whatsapp group chat for a party’s comms team), people from various think-tanks, academics (including an Emeritus Professor from Imperial who had a lot to say), and a representative from at least one (non-militant, at least in the room) campaigning group.

    The line up:

    • Sarah Wollaston MP, Chair of the Health Select Committee and medic who worked as a GP up until 2010. (Given her generally sensible views, I keep having to remind myself that she’s a Tory).
    • Jon Ashworth MP, Shadow Secretary of State for Health, who has a long history as a Labour professional, including as Special Adviser in the Treasury for Gordon Brown.
    • Ben Page, Chief Executive of Ipsos MORI and fellow of the Academy of Social Sciences.
    • Matt Whittaker, Deputy Director at the Resolution Foundation, who previously worked for the House of Commons Library where he provided stats and economics advice.

    The event was chaired by Torsten Bell, Director of the Resolution Foundation, former adviser to Ed Miliband (and, incidentally, architect of the Ed Stone).

    Interlude: What is the Resolution Foundation?

    The launch was set at Resolution HQ in a bright, wide room, with cosy luxurious seats which wouldn’t be out of place in an up-market indie cinema, so I was curious who they are and how it’s all funded.

    Resolution Foundation’s website describes it as “a non-partisan and award-winning think-tank that works to improve the living standards of those in Britain on low to middle incomes.” In their most recent annual report, they defined “low to middle” as those in income deciles 2 to 5, whom they say are overlooked in policy debates. Their focus is on working households.

    They receive most of their funding via donations from Resolution Trust, founded by Clive Cowdery with a £50m donation, “believed to be one of the largest endowments for public policy research made in the UK”.

    Cowdery made his wealth from “sponsoring insurance vehicles” (an FT article says more) and is also founder of financial services investment firm called (again) Resolution.

    Resolution Trust backs Prospect Magazine and, intriguingly, WorkerTech, which seems to be about encouraging alternatives to trade unions for the precarious world of Uberified work. (Here are slides from its launch.)

    What did they say on health funding?

    All agreed that the NHS needs more funding, so the question is how much more funding and where the money is coming from. The issue was framed as a tug-of-war between Treasury and Jeremy Hunt (with Hunt wanting more money, in case not clear – it’s not always obvious), constrained by a complex parliament and a wish to keep voters happy.

    Matt Whitaker took us through some headlines from the Resolution report, emphasising that it was a prediction of what the government was likely to announce rather than what it should do. (Though it sounded very much like advice.)

    Borrowing was seen as likely necessary, so long as the total was below 2% of the projected GDP in 2020-21 (to meet a Tory fiscal target). But borrowing alone would not suffice, so some sort of tax raise is almost certainly on the cards – the problem is how to keep keep Tory voters and donors on side, whilst getting it through parliament.

    One possibility is increasing National Insurance contributions (or NICs, pronounced “nicks”), which Gordon Brown did when he was chancellor. This is a progressive tax for workers; however, increased NICs was seen by the report authors as “unfair from a generational perspective” since older people who rely more on healthcare don’t pay national insurance (this generational perspective might need some analysis). A solution proposed was to extend NICs to include those above state pension age who are still working.

    Increasing income tax could be another way to get the money. LibDems and SNP might support this, and Scotland recently introduced a change to its tax bands meaning some pay more and others pay less tax. Labour, the authors argue, would likely oppose increases for anyone earning under £80k and some Tory MPs might oppose too.

    Another approach suggested was to adjust thresholds for (i) when income tax is payable and (ii) the higher rate of payment. Threshold changes were Tory manifesto promises, but the authors suggest a fiddle (p. 24):

    “An alternative approach would be to lift the Income Tax thresholds to those pledged in the manifesto in 2020-21, but to freeze both them and the NICs thresholds in the final two years of the parliament. This would of course cost money in 2020-21, but by 2022-23 it would raise £3.7 billion relative to the default of uprating in line with inflation every year.”

    Another promising source of funding would come from reversing George Osborne’s 2016 pledge to cut corporation tax by 2020. This tax uncut could provide £5.2 billion in 2020-21 and £5.7 billion by 2022-23. Other political parties would likely support the move and the authors argue (p. 27):

    “The Chancellor might also feel emboldened to act given the way in which the estimated costings of the move from 19 per cent to 17 per cent have shifted since George Osborne first announced it.”

    Remarkably little was said about Brexit. Will it torpedo all the projections and render the suggestions (sorry, predictions?) unimplementable? The exception was Sarah Wollaston, who noted that she never believed the infamous £350m bus claim; she expressed reasonable worries about the effects Brexit would have.

    What might more money mean for mental health?

    Although the focus was very much top-level – where’s the money? – speakers did say a little about how it should be spent. For instance, Jon Ashworth quoted numbers on additional doctors and nurses required (it’s thousands), citing a report from IFS – also cited by Sarah Wollaston.

    Reassuringly, mental healthcare was mentioned a few times as being important and in need of improvement (though note the history of “warm words”). Ben Page cited public support for increased spending, with mental health being second on the list in an April Ipsos MORI survey of priorities, after Accident and Emergency. Jon Ashworth mentioned improving support for addictions, in particular.

    Sarah Wollaston cited the Health and Social Care Committee’s report into integrated care, published yesterday, which discusses detailed contractual changes needed to improve how, e.g., mental healthcare integrates with other services, including discussion of accountable care organisations (ACOs). (Perusing this report just now highlights how difficult it is to have public debates on these issues – it’s technical stuff.)

    The coming weeks as we approach July 5th would be a good time to campaign for key specifics on how much money mental healthcare should receive and what it should be spent on. If the NHS received £20 billion more in 2022-23, how much should go to mental health and where?

    First published on Andy Fugard’s blog


    Mean societies produce mean people

    Babies haven’t changed much for millennia. Give or take a few enzymes this perfectly designed little bundle of desires and interests has not needed to evolve much. Of all primates, the human is the most immature at birth, after which brain growth accelerates and is ‘wired’ according to the kinds of experience the infant has. Provided there are a few familiar and affectionate people there to care continuously for him or her, baby will be fine. If not, evolution has taken care of that too. You live in a cruel world and treat him roughly? He will develop into a compulsively self-reliant and ruthless individual with little concern for others. Mean societies produce mean people. Through attentive care in the early years we may hope to produce thoughtful, curious and confident young people but our social arrangements are essentially hostile and competitive. Having a baby is regarded as an expensive undertaking rather than as a contribution to the future of society.

    Encouraged by successive governments our world is geared to markets. “It’s the economy, stupid” means you can’t do anything without considering the immediate cost. The more this idea takes hold the stupider we become. The current government’s dedication to continuous welfare cuts hits children disproportionately. Neoliberalism is the enemy of children.

    Evolutionary imperatives

    This is not the environment in which humans evolved. An infant in a hunter-gatherer band – the way we all lived for 99% of our time on the planet – would have spent many hours being held, and not only by the mother. “Infants with several attachment figures grow up better able to integrate multiple mental perspectives”. We are programmed from the start to seek out third positions, to acquire the “capacity for seeing ourselves in interaction with others and for entertaining another point of view whilst retaining our own, for reflecting on ourselves whilst being ourselves.”

    Systematic comparisons between sedentary foraging and farming people living now in neighbouring parts of the Congo basin show how much more egalitarian the foragers are. Men and women see themselves as equal. They hold and converse with their tiny children more intensively, they let the baby decide when to wean and teach them to share from an early age. Violence is rare, though teasing is common. Such children are more socialised than in the west and at the same time protected from catastrophe in the event of the mother’s death. Amongst the farmers, in contrast, “corporal punishment is not an uncommon response for young children who do not listen to or respect their parents or older siblings”.

    In the modern world little public money is available for perinatal services, parental leave, for quality child care and universal education, affordable and secure homes, healthy food, subsidised transport and energy, sports fields, swimming pools, libraries, parks and playgrounds that make rearing children and adolescents more manageable and more successful. Tax, like children, is seen as a ‘burden’. So governments of all parties sign up to reducing it, yet still find money for bank bailouts and unsustainable wars. Whether local or national, tax should be a contribution to the common good, an instrument of social justice. It is collected from citizens, for citizens. In the current climate this equation is neither acknowledged nor understood. Yet something has been understood that was not clear before. There is a greater recognition that early intervention is a good idea: “the brain can be sculpted by experience”; the sooner the better.

    Start at the beginning

    When a woman becomes pregnant her physical and mental states impact on her child. From conception onwards the health and resilience of children – and the adults they will become – is compromised by stress, diet, maternal weight, drugs, genes and insecurity in their parents. Besides the impact on the mother herself, anxiety and depression during pregnancy and after it have significant long term effects on the child’s physical and mental health – particularly on boys – generating huge social costs. Pregnancy is a dangerous time for some women. The most socially deprived mothers are more likely to have very premature births or perinatal death. Low birthweight leads to poor outcomes; early intervention can reduce that.

    Elegant research shows how already by a few months old babies are engaged in triadic relationships; they are affected by tensions between the adults caring for them. When caregivers are uncooperative infants may be “enlisted to serve the parents’ problematic relationship rather than to develop their own social competence”. Children will more likely thrive if caregivers – parents and grandparents, childminders, daycare and children’s centre staff, nursery teachers – get on with one another, like a good team. “Communication between parents and care providers is crucial to the quality of care.”

    The routine availability and presence of health visitors and other staff supporting new parents and of Sure Start centres for children and families create the conditions for reliable care of children. In a context of skilled early years provision, infants whose parents are paid to spend time with them in the early months are less likely to die. “A ten week extension in paid leave is predicted to decrease post neonatal mortality rates by 4.1%”. This remarkable finding represents just the tip of an iceberg of developmental damage and pathology, modifiable by intensive early support for families.

    Better training and pay for early years staff improves outcomes and reduces turnover. UK needs to learn from continental Europe the tradition of pedagogic professions: proper pay, status and training for the job, particularly when the families most in need are hard to engage. Looking after small children is demanding and stressful, requiring continuous professional development such as reflective discussion groups in which colleagues both support and learn from each other. Work with young families is a professional skill.

    Inequality undermines trust

    A collaborative partnership between caregivers does not in itself cost money, but is undermined by social disintegration, the most poisonous source of which is rising inequality. In Britain this has reached levels not seen since the 1920s. The much maligned 1970s was actually the most egalitarian in our history. Consider this: one index of social health is the number of boys born in comparison to girls. Because the male fetus is more vulnerable to maternal stress, women produce fewer boys when times are hard. (For example there is a fall in the ratio of boys to girls a few months after disasters such as massive floods or earthquakes, or the terrorist attack on 9/11). In England and Wales the highest ratio of boys to girls occurred in 1975. In terms of contented mothers it was the best of times.

    Inequality creates stress in parents who can’t keep up, and anxiety in the better off who fear sliding down. No one is comfortable on a steep slope. It makes all of us less trusting and more averse to communal commitments, such as respecting our neighbours and paying tax. Infant mortality, mental illness, drug abuse, dropping out of education, rates of imprisonment, obesity, teenage births and violence are all higher in unequal countries like ours.

    Though often disappointed, our ancient baby is born to expect some kind – a rather conservative kind – of socialism. What will today’s infants be talking about in 2050? If they know any history they will regret lost opportunities; our collective loss of vision that led to wasted generations. The success of the post war consensus was due in part to the fact that it lasted longer than one or two parliamentary terms, so that children could grow up, get educated and housed, find partners, get work and free healthcare without overwhelming instability or despair. The needs of a baby born today are precisely what they were for one born in the 1950s, or 50,000 years ago. New knowledge of infant development is catching up with evolved wisdom, yet we continue to ignore both, and build bigger obstacles to secure attachments.


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    ‘U-turn’, ‘Fiasco’, ‘Chaos’ – Personal Independence Payment (PIP) has been back in the news at the start of 2018 and the headlines don’t make good reading for the government. Back in March 2017, the government changed the eligibility criteria for the mobility component of PIP to exclude claimants experiencing ‘psychological distress’ from receiving the enhanced rate of the benefit. However, the High Court found that the government’s amendments ‘were blatantly discriminatory against those with mental health impairments and cannot be objectively justified, and concluded that ‘the wish to save nearly £1 billion a year at the expense of those with mental health impairments is not a reasonable foundation for passing this measure.’

    The government decided not to challenge the High Court’s decision and now need to undertake a review of 1.6 million claims made for PIP over the last four years at an estimated cost of £3.7bn. It is understood that the review could take up to five years and result in 220,000 claimants receiving higher awards. What, then, does this recent development tell us about the adjudication of disability benefits for people with mental health problems? More broadly, what does it tell us about the ideology and administration that underpins PIP?

    Personal Independence Payments and mental health

    PIP was launched by the coalition government in April 2013 and was intended to assist claimants of working age with the costs associated with disability or long-term health conditions. The government argued that by replacing Disability Living Allowance, PIP would provide more targeted support for those in genuine need with decisions based on medical evidence. Initially, it was anticipated that the full roll-out of PIP would result in 600,000 fewer disability benefit claimants and annual savings of £2.5 billion. Analysis shows there are likely to be ‘winners’ and ‘losers’ from the new PIP regime, but this is difficult to accurately assess because the government has changed the timescales for its implementation and the standards for qualification.

    The uncertainties created by the transition to PIP are a real issue for many people with mental health problems. It is not unreasonable for someone with mental health problems to ask, ‘Am I likely to get PIP?’ or ‘When will I have to go for a PIP assessment?’ At the moment, the system is so fraught with uncertainties and inconsistencies that these are very difficult questions to answer. And surely the whole point of a social security system is to provide some security for claimants.

    I am in the early stages of a research project exploring the impact of the rollout of PIP and claimants with mental health problems have repeatedly told me that their mental health has been negatively impacted by the unpredictability of the system. Consider the following timeline of events over the last 12 months:

    • 23 February 2017: Department for Work and Pensions lays regulations before parliament that amend the eligibility criteria for the mobility component of PIP for those unable to undertake journeys due to psychological distress. It is estimated that this change would result in nearly 300,000 people no longer being entitled to the mobility part of PIP and will affect people with a range of conditions including schizophrenia and anxiety conditions. The government state that this amendment is necessary to restore the original aims of PIP.
    • 21 December 2017: The High Court found that the government’s amendments amount to direct discrimination against those with mental health impairments and the policy intention to save money was based on an untestable hypothesis about levels of need.
    • 19 January 2018: New Department for Work and Pensions Secretary Esther McVey states that the government will not challenge the High Court decision and a review of 1.6 million claims for PIP will be undertaken.

    A charitable view of this timeline would be of the government and judiciary applying scrutiny to a new benefit in order to get things right. However, the impact on claimants, particularly those with mental health problems, is often damaging. Not surprisingly, the second independent review of PIP completed by Social Security Advisory Committee chairman Paul Gray and published in March 2017 described an ‘inherent distrust’ in the system by claimants. This means that a benefit system which should provide a safety net is, in fact, exacerbating anxiety for those living with mental health problems.

    Criticism of the UK disability benefits system has also come from the UN Committee on the Rights of Persons with Disabilities, which found in 2016 that ‘there is reliable evidence that the threshold of grave or systematic violations of the rights of persons with disabilities has been met in the State party’. The committee recommended that the UK government should improve the administration of disability benefits and make it more accessible for disabled people.

    Delayed implementation and chaotic administration

    It should be acknowledged that designing and administering a disability benefit is not an easy task and this is underscored by the fact that few other countries have a comparable benefit to PIP. The eligibility criteria for PIP focuses on claimant’s ‘limited ability’ in relation to mobility and a range of daily living activities. This, in itself, seems reasonable, but as with all social security, the devil is in the details. Unfortunately, with PIP, the details seem to have focused on saving money and reducing the number of claimants.

    The government appear to have overlooked the fact that the needs of disabled people don’t vanish because tighter benefit rules are introduced. This is important as the concessions that the government have been pressed into making are largely because claimants and disability campaigners have been able to clearly demonstrate (often through the tribunal and court system) that significant elements of PIP are not fit for purpose. An ill-conceived policy that seeks to save money invariably ends with compromise and additional cost that was not initially intended. It will be interesting to see to what extent the government’s initial forecast in terms of expected savings and number of claimants has changed once its review of PIP claims is complete.

    The government’s intention was that PIP would create a more fair and objective assessment of need. However, from the early stages of the rollout of this benefit, there has been intense criticism of the assessment and adjudication process. Early concerns were voiced by the National Audit Office and the Work and Pensions Committee about unacceptable delays in the decision-making process. While there have been some improvements in this area, the second Gray review of PIP found that administrative processes need to be significantly improved. This should include improvements to the way evidence is obtained and the need ‘to broaden audit and quality assurance in assessment and decision-making.’ For many claimants, the experience of the PIP assessment process can be as damaging as the final decision that is made, with many reporting cancelled appointments, rushed assessments and a lack of understanding of individual conditions and resulting need. As with other areas of policy, the appropriateness of the involvement of private contractors (ATOS and Capita) has been questioned.

    We should also recognise that public and judicial pressure are not the only reasons for the government U-turn on PIP. The challenges that the government face with the Brexit negotiations mean they must choose their domestic battles wisely and it seems that a fight over PIP was a step too far for Theresa May. (Remember, this is a Prime Minister who chose social justice as one of the central themes of her maiden speech.) While campaigners and social policy academics will rightly welcome the government climb-down on PIP, we must not forget that this creates yet more uncertainty for disability benefit claimants. Rather than a system underpinned by a fiscally-driven ideology, shaped by short-term political considerations and delivered in a chaotic manner, what we really need is a ‘real-world assessment’ of disability and a benefit which appropriately meets the needs of claimants.

    First published by the Social Policy Association

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    In recent years we have made great strides in the UK, not only tackling the stigma around mental illness but have also seen the issue of mental health rise to the top of the political agenda. In June 2012, Charles Walker MP and I both spoke in parliament about our personal experiences of mental illness, something which at the time was seen as groundbreaking. I am pleased that people from all walks of life have spoken about their experiences since then, adding to the debate to ensure that mental illness is no longer seen as the taboo it once was. Campaigns such as Time for Change and the work done by mental health charities have also made a real difference in changing attitudes. So, if we are winning the battle against the stigma around mental illness, what should the next steps be?

    Firstly, we need to hardwire mental health and mental wellbeing into policy-making and secondly, we need to make the economic case for good mental health.

    In response to the increased debate on mental health, the government established an independent mental health task force in 2015, which was widely welcomed and resulted in the NHS Five Year Forward View for mental health. Its plans are ambitious, but success will depend on resources and the buy-in from the various actors in a fragmented National Health Service. Only time will tell if this well intentioned policy bears fruit, but a more fundamental change across government in policy-making is needed.

    All new government policy, across all departments, should be road-tested against mental health and mental wellbeing objectives. There also needs to be a cabinet committee at the heart of government which has a series of mental health and mental wellbeing tests that policies need to pass before they can be adopted. This would embed mental health and mental wellbeing into the policy-making process throughout Whitehall.

    Clearly this is not happening now. You only have to look at the roll out of personal independent payment to see this. Mind – the mental health charity – found that 55 per cent of those surveyed with mental health conditions lost all entitlement or had their benefits reduced, and 22 per cent felt unable to appeal against the decision. I know from speaking to my constituents that the main problem is that those assessing claimants have little or no knowledge of dealing with people with mental health conditions. The result is a system aimed at supporting some of the most vulnerable in our society, making the situation worse for them and possibly leading to increased costs for the NHS because of individuals’ mental health deteriorating. If this policy had been tested for its suitability to meet the needs of those with mental health conditions we could have avoided much of the distress and anguish caused to some of the most vulnerable people in society.

    Having such a system at the centre of government would ensure that mental health and mental wellbeing would be at the heart of departmental policy-making, turning many well intentioned words into meaningful action.

    At a time of austerity, why is change needed? The answer is simple – it makes economic sense too. In the debate around mental health and mental wellbeing the economic case is one which often only gets a passing reference. Dennis Stevenson and Paul Farmer’s excellent report Thriving to Work dramatically sets out the case for why good mental health is important to the UK economy. It found that the cost to UK economy of poor mental health is between £74bn and £99bn per year, with an additional cost to government of between £24bn and £27bn per year. The report was commissioned by the government and has several recommendations both for the private and public sector. It recommends the establishment of a mental health employers’ leadership council to drive the implementation of mental health work plans for employers. It also argues for using public procurement as a way of incentivising the adoption of such plans. The public sector employs 5.4m people and provides an opportunity to start the implementation of the report’s recommendations.

    Though these proposals are ambitious, with enough political will they can make a real difference. Some will argue that they will be an added burden on business, but if you look at some of those companies already implementing such policies like BT, the economic benefits can already be demonstrated.

    With the continued debate about Britain’s future following Brexit there are those who would argue that concentrating on the nation’s mental health is not a priority. But I would argue it is not just the right thing to do for the wellbeing of our citizens, but it is vital for the future of the UK’s economy.

    Now is the time to turn all of the well intentioned words on mental health into action.

    This first appeared on the Fabian Society’s health network blog


    Core principles of the PTM Framework

    The Power Threat Meaning Framework is a new perspective on why people sometimes experience a whole range of forms of distress, confusion, fear, despair, and troubled or troubling behaviour. It is an alternative to the more traditional models based on psychiatric diagnosis. It applies not just to people who have been in contact with the mental health or criminal justice systems, but to all of us.

    The Framework summarises and integrates a great deal of evidence about the role of various kinds of power in people’s lives; the kinds of threat that misuses of power pose to us; and the ways we have learned as human beings to respond to threat. In traditional mental health practice, these threat responses are sometimes called ‘symptoms’. The Framework also looks at how we make sense of these difficult experiences, and how messages from wider society can increase our feelings of shame, self-blame, isolation, fear and guilt.

    The main aspects of the Framework are summarised in these questions, which can apply to individuals, families or social groups:

    • ‘What has happened to you?’ (How is Power operating in your life?)
    • ‘How did it affect you?’ (What kind of Threats does this pose?)
    • ‘What sense did you make of it?’ (What is the Meaning of these situations and experiences to you?)
    • ‘What did you have to do to survive?’ (What kinds of Threat Response are you using?)

    In addition, the two questions below help us to think about what skills and resources people might have, and how we might pull all these ideas and responses together into a personal narrative or story:

    • ‘What are your strengths?’ (What access to Power resources do you have?)
    • ‘What is your story?’ (How does all this fit together?)

    Possible uses of the PTM Framework

    The Power Threat Meaning Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they may have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or ‘mentally ill’. It highlights the links between wider social factors such as poverty, discrimination and inequality, along with traumas such as abuse and violence, and the resulting emotional distress or troubled behaviour. It also shows why those of us who do not have an obvious history of trauma or adversity can still struggle to find a sense of self-worth, meaning and identity.

    The Framework describes the many different strategies people use, from automatic bodily reactions to deliberately-chosen ways of coping with overwhelming emotions, in order to survive and protect themselves and meet their core needs. It suggests a wide range of ways that may help people to move forward. For some people this may be therapy or other standard interventions including, if they help someone to cope, psychiatric drugs. For others, the main needs will be for practical help and resources, perhaps along with peer support, art, music, exercise, nutrition, community activism and so on. Underpinning all this, the Framework offers a new perspective on distress which takes us beyond the individual and shows that we are all part of a wider struggle for a fairer society.

    One of the most important aspects of the Framework is the attempt to outline common or typical patterns in the ways people respond to the negative impacts of power – in other words, patterns of meaning-based responses to threat. This part of the Framework, like all of it, is still in a process of development. However, the evidence summarised in the Framework does suggest that there are common ways in which people in a particular culture are likely to respond to certain kinds of threat such as being excluded, rejected, trapped, coerced or shamed. It may be useful to draw on these patterns to help develop people’s personal stories. These general patterns can help to give people a message of acceptance and validation. The patterns can also assist us in designing services that meet people’s real needs, as well as suggesting ways of accessing support, benefits and so on that are not dependent on having a diagnosis.

    In addition, the Framework offers a way of thinking about culturally-specific understandings of distress without seeing them through a Western diagnostic model. It encourages respect for the many creative and non-medical ways of supporting people around the world, and the varied forms of narrative and healing practices that are used across cultures.

    Taking the PTM Framework further

    It is important to note that Power Threat Meaning is an over-arching framework which is not intended to replace all the ways we currently think about and work with distress. Instead, the aim is to support and strengthen the many examples of good practice which already exist, while also suggesting new ways forward.

    The Framework has wider implications than therapeutic or clinical work. The main document (link below) suggests how it can offer constructive alternatives in the areas of service design and commissioning, professional training, research, service user involvement and public information. There are also important implications for social policy and the wider role of equality and social justice. It is a work in progress, offered as a resource for any individuals, groups or organisations interested in developing it further.

    This link will take you to FAQs; the project documents; a possible ‘Guided discussion’ for one to one work in services or for peer support/self-help; and soon, a video of the main talks from the launch.  Appendices 2-14 in the Overview Document give examples of good practice in various service and non-service settings.

    An interview with the lead author is here.

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    Yes we need more resources in mental health but not the same old ‘diseased’ bio-psychiatric medical model of mental ‘illness’ and mechanistic Cognitive Behavioural Therapy,  but a social-social public health preventive model of mental distress/health, health workers who firstly tackle the social determinants of health and work amongst the people where the social is not forgotten.

    No one is denying the reality of mental distress, also mental distress needs twenty times more resources than at present, but the question is “what type of resources and interventions?” Does anyone ever stop to analysis why mental health issues are occurring. What is the cause that causes the cause to become a cause? Is it diagnosis which is so wide e.g. DSM5, that everyone is now mentally ill?  Is it iatrogenesis? Is it the ideology of austerity? Is it the treatments with so called anti psychotics and anti – depressants? Is it coercive mental health laws?  Is it unfairness, poverty, inequalities? Is it abuse and discrimination? Is it a cruel state, poor working conditions, deregulation and privatization? is it individualising, psychiatrising, psychologising existence so that the social, political, economic, materiality and broad environmental issues conveniently disappear? Is it capitalism, society, which causes so much mental distress? Why are so many people internalising their own oppression, harming themselves? Why not externalise their distress come to voice. There are many people who would like to work in mental health but not one dominated by psychiatry and mechanistic CBT.

    Psychiatry is a pseudoscience with a faulty epistemology  and wrong, very wrong, ontology. What is a human being – not just DNA or neurochemical selves. Humans are social beings and how society is socially, economically politically and environmentally (SEPE) arranged influence much including mental health and distress.

    Many people who go into the psychiatric system have just normal emotions, reactions to situations, e.g. bullying, all forms of abuse, power-over, lack of autonomy and control, alienation, homelessness, trauma, unfairness and poverty. Many have been drugged (iatrogenesis doctor induced illness) into psychiatric services as Whitaker (2010), clearly and with evidence illustrates over the last sixty years people have been medicalised and damaged.  Psycho-trophic drug giving has ‘sky rocketed’ leading to an explosion of chronic mental health and physical disabling conditions.  Q if the drugs are so good why has chronic mental health conditions increased so much in the last 40 years – madness. No one is denying the reality of mental distress. People suffer suffering is not an illness. Psychiatry is a marriage of convenience with neo-liberalism, big pharm, corporations, governance (control of the populace) – a form of ideological hegemonic power.

    Surely all the children in USA/UK now medicalised with toxic drugs aren’t all mad? Did the children ask for these drugs? Do all women and the poor placed in institutions by husbands, families consider themselves mad, are all the Jews exterminated by German psychiatrists in T4 camps did they consider themselves mad? Are all BME groups labelled and tortured by psychiatry would they consider themselves mad?  The Soviet dissidents tortured in Russian and sent to gulags would they consider themselves mad? Are all the people getting on in years and particularly women given electric shock at alarming increasing rates are these people mad?

    When you listen to people who have experienced abuse, rape, power-over, poverty, trauma including psychiatric trauma and psychiatric rape, experienced a cruel state, would they consider themselves mad? Maybe nearly driven mad but that’s another issue.

    What can be called mad is a biological and genetical, nonsense aetiology which still prevails. When in the 21 st century today’s scientists are aware of epi-genetics and that genes get switched on and off and are influenced by social economic political broad environmental  issues including poor diet. The genome studies again have found no conclusive findings for biological explanations for mental distress.  Mad is the four ideological myths of psychiatry (chemical imbalance, 1960’s marketed drug ‘illness model of drug action, pseudoscience of diagnosis, biological biomarker myth) and the reality of coercion and iatrogenic mad practices. Another madness is the invention of illness DSM and all classifications, fabrications of psychiatry. Thinking that psycho-trophic drugs will cure mental distress is another madness. Nor providing the social determinants and the prerequisites for health and wellbeing is mad also really a crime against humanity. Psychiatry is a crime an industry of death.

    Some people  state it is  naïve to want to abolish psychiatry without putting something in its place  – to abolish psychiatry is a necessary prerequisite for change and it is naïve not to want to do this. Replace it with more doctors of medicine MD’s, they are trained to deal with health problems – adopt a new approach to mental health, a public health approach, adopt community preventative medicine, not dualistic but holistic including changes in SEPE – increase resources for mental distress twenty times fold – not less resources but more. Have a 100% state funded NHS, have no private provision in NHS, have a national work occupation health service in all organisations to promote health and reduce mental distress. But don’t have a national sickness service have a health service.  More up – stream public health measures preventing and enhancing health, a more just society, reduce relative income differences, introduce a universal wage. There are numerous alternatives – open dialogue, exercise, social solidarity, Hearing Voices Network, peer groups, Sorteria houses, dial house in Leeds, activity for life, retreats, safe spaces, quiet spaces, night cafes, more social engagement, better healthy workplaces promoting autonomy control and income and so on. Adopt a social model of health and mental distress tackle alienation. Just stop abuse. Maybe social transformative change has to occur before psychiatry is abolished? Just think if annoyed, angry, discontented, irritable, unhappy, grief stricken, miserable people, put upon people, people disadvantaged, ‘down depressed’ people, agitated people, traumatised people, abused people, decided to use this energy as a catalyst joining alliances to change things, demand a less abusive fairer society, that would upset the status quo.

    This author acknowledges the reality of serious mental distress which needs resources but the crucial question is what type of resources. It also acknowledges that some people are happy with present day mental health services and drugs but others are not. Many people are trapped and damaged by the drug regime.

    If you get rid of the ideology of psychiatry and psychiatry itself, there will be less stigma more possibilities. One can easily make a case that capitalist society  makes you mad – isn’t education mad, testing children, pressurising children, labelling children – too much I.T  and  social media pressure, too much computer time, sedentary children inducing future public health ‘time-bombs’-  isn’t this madness?

    These are not just issues of the past. They are happening now and will happen in the future if psychiatry isn’t abolished. We are drugging people and damaging them, some drug use will still be required, there is a role but use the correct drug induced model of drug action, be truthful with people and use drugs with extreme caution and only mainly short term. Electric shock, psycho-prisons, Community Treatment Orders, harmful mental health laws are still used. Human rights violations are very much still rampant. So who is mad? Surely not the people, surely not children and the poor,  not the politically constructed ‘race’ people.  It isn’t psychiatric neglect but SEPE neglect, social justice neglect, materiality, power and resources neglect and psychiatric abuse. It is also an abuse that there is very little resources for mental distress but these are decisions made by people in power with vested interests in the status quo. Just think how much money we could save without a pill for ever ill. Just think how many people could be saved from chronic disabling mental health conditions, how many children could be saved. This money could be used in mental health on alternative schemes and up –stream public health to prevent health problems.

    Here is the crux many people have a vested interest in psychiatry, and the psych industry unfortunately they are also very powerful in a neo-liberal state and the ideology of individualism, a form of social control and it’s an ideal way to make profits.

    One person with a similar aim and viewpoint – Bonny Burstow (2015) her latest excellent book Psychiatry the Business of Madness: an epistemological and ethical audit advocates an abolitionist approach.

    Revision after consulting the public in four workshops and 14 discussion groups  have recently  come up with a manifesto for change which will be launched in 2017

    Revisions Manifesto’s seven visions for change:

    1. To move from a ‘diseased’ bio-psychiatric model of ‘mental illness’ to a social model of mental distress/health. We need for a different approach ‘grounded’ in social fairness, listening, equity and social justice.
    2. To  stop using all psychiatric diagnostic and classification systems
    3. To recognise what we need to achieve good mental health :
      1.  Income, family, friendships, a safe home, opportunity, work, leisure, the arts, spirituality – plus many more which should be defined by individuals and communities themselves.
      2. Recognise oppression in all its forms and develop strategies to combat these at the individual and structural level.
    4. To understand that medication does not and cannot ‘cure’ mental distress.
    5. To work towards socially orientated and democratically accountable types of mental health service provision.
    6. To stop coercion – abolish Community Treatment Orders, ban electroconvulsive therapy  and urgently review all mental health laws.
    7. To challenge the current crude neo-liberal economic system that creates a fertile environment for ever increasing mental distress.

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    Socialist Health Association’s motion to the Young Labour Policy Conference:

    Young Labour notes:

    1. Self harm and suicide have continued to rise in the last 20 years, and for young people in the U.K. rates are now among the highest in Europe, according to the Royal College of Psychiatrists.
    2. NHS Providers reported in July that demand for Child and Adolescent Mental Health services rose 44% from 2013 to 2016, far outstripping growth in demand for physical healthcare.
    3. Acute mental health crises are manifestations of emotional distress, and can be seen as a symptom of a often complex mix of difficult personal circumstances, past traumas and social and economic deprivation. It is associated with long term mental health problems and drug and alcohol abuse.
    4. There are higher rates of self harm among prisoners, asylum seekers, veterans from the armed forces, people bereaved by suicide, some cultural minority groups and the LGBT community.

    Young Labour believes:

    1. The social context of self harm and suicide demands a cross-sectoral approach, in the form of community based mental wellbeing collaboratives, linking health providers with other stakeholders including councils, youth work teams, schools and colleges, ambulance services and police. Minimum standards of timeliness and quality of care should be guaranteed by a new National Service Framework for Mental Health.
    2. For young people this means focusing on:
      1. timely access to evidence-based care;
      2. targeted interventions on drug and alcohol use;
      3. anti-stigma campaigns; and, most importantly,
      4. addressing systemic causes of social exclusion.
    3. Erosion in funding for primary and secondary mental health care must be reversed, with the aim of achieving parity of funding. (That is not to say that funding should be mathematically equal to funding for physical health, but that the level of funding should be determined systematically according to need.)
    4. A National Strategy for Mental Health should be created to improve the resilience of communities across the board and should include but by no means be limited to:
      1. improving the capacity of schools to offer help and support for those struggling;
      2. restoring universities as places of learning rather than competition;
      3. providing funded apprenticeships and pathways to meaningful and secure jobs;
      4. providing access to secure, good quality and affordable housing;
      5. improving funding to mental health care so that more holistic care can be provided in emergency settings; and
      6. offering mental health training to all those in key roles such as teachers, police, job centre staff, councillors, and allied healthcare professionals so they can respond sensitively and appropriately to crisis.


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    This is a discussion document not agreed policy.

    Mental Health services are “overwhelmed” by soaring demand according to a report by the body representing community, ambulance and hospital service providers, NHS Providers (July 2017, ref 1). Demand has increased by 5-10% over the last 3-4 years, but by 30-40% for children and young people. Patients are facing long delays to access mental health care, and people too often receive inadequate treatment. The numbers of people in need of specialist post-trauma mental health services has escalated dramatically following recent terrorist and civilian disasters. These intractable problems are the result of the Conservative Government’s unremitting policy of economic austerity, the prolonged real terms reduction of NHS funding over the past 7 years, and worsening shortages of key mental health staff such as nurses and psychiatrists.

    The Socialist Health Association is committed to ensuring fulfilment of repeated high level commitments to ‘parity of esteem’ for mental health, and urgent implementation of proposals set out in the cross-agency Five Year Forward View for Mental Health (February 2016, ref 2) and Five Year Forward View for Mental Health: one year on’ (February 2017, ref 3). This must be combined with the future freedom from political interference of NHS policy making and delivery.

    mental health

    The origins of mental wellbeing and good mental health

    The SHA policy on mental wellbeing is founded on the recognition that societal factors impact significantly on the whole spectrum of mental wellbeing to mental ill-health. The effects on individuals and families of social deprivation impacting on income, debt, access to appropriate accommodation, rewarding employment and security of tenure, community and family support networks, the availability and content of education, and other factors all play their part. The physiological reactions to stress of an expectant mother with pressing social difficulties affect the developing brain of her child. Experiencing or witnessing abuse and violence in the domestic setting at an early age can have severe lifelong effects on mental wellbeing and health.

    In addition to the effects of absolute deprivation, living with extreme socio-economic inequalities has an independent impact: the experience of being judged socially inferior is a chronic cause of stress with negative effects on physical and mental health. Even severe mental illnesses with a genetic component are influenced by such social factors.

    ‘’.. . although genetic vulnerability may underlie some mental illness, this can’t by itself explain the huge rises in illness in recent decades – our genes can’t change that fast.’ Richard Wilkinson and Kate Pickett – The Spirit Level.

    Virtually every aspect of policy – economic, housing, education and training, environment, equalities, health and social care – impacts on mental wellbeing, and should be seen clearly and addressed collaboratively to serve the promotion of good mental health, personal autonomy, and full access to civil society. At the same time, responsibility for determining and delivering health and social care must be freed from the highly disruptive cycle of repeated organisational change and political interference in NHS management.

    Promoting knowledge, support, and care

    A general understanding of the promotion of mental wellbeing, and the way mental health problems are manifest should be promoted at all levels in society through ante-natal care, children’s centres, school and further / higher education, to places of employment, and this should be a central facet of a National Strategy for Public Health.

    The vast majority of people with mental health problems, including those who need highly specialised inputs to their management, will rely on primary and community care for diagnosis and ongoing care and support. For the large number of people who have both physical health and mental health problems these are managed together in primary care. Access to social support and integrated resources can best be managed by community based mental wellbeing collaboratives bringing together service users and carers, community groups including ‘Being Well’ projects (Plunkett Foundation: ) commissioners, voluntary sector organisations, local authority services, and primary and secondary health services.

    To make these effective,

    1. The severe reduction in funding for primary care, and in particular general practice, must be reversed urgently
    2. Community based mental wellbeing collaboratives (see above) should be established in all areas, with appropriate public health support.
    3. The progressive and continuing erosion of funding for mental health services, itself the product in part of continuing real-terms reduction in funding for the NHS more widely, must also be reversed urgently and in line with ongoing rhetoric about ‘parity of esteem’ for mental health. Parity should not mean a race to the bottom for mental, physical and social health funding.

    Specific SHA policy recommendations include:

    1. Parity of funding for the prevention of, treatment services and related social care for, and research into mental ill-health; and for treatments including psychological alternatives to medication; and funding to ensure research findings are applied in clinical practice more quickly. To reflect the accepted burden of disease, 23% of NHS spend should be committed to secondary mental health service provision rather than the present 13%. Funding must be ring-fenced.
    2. An integrated cross-party, cross-government National Strategy for Mental Health including public education, universal support, and clear policies for tackling the societal determinants of poor mental health, ie poverty, debt, housing need, low educational attainment, low employment aspiration and community disintegration.
    3. A new National Service Framework for Mental Health drawing on the ‘Five Year Forward View for Mental Health’ and linked to the National Strategy for Mental Health, incorporating urgent review and reinstatement of national standards for mental health service provision, including for illness prevention and improved access to services.
    4. Establishment of an Independent National Health and Social Care Service Commission to oversee the rapid integration of health and social care, and to govern a new National Health and Social Care Service in future free from party political interference.
    5. Confrontation and breaking down of stigma should be a fundamental part of mental health strategy – this requires more public information and education about mental illness, the building of community cohesion, how to help oneself, and about the principles of early intervention.
    1. Improved and better resources including mental health services in Primary Care / General Practice, funded in addition to and not at the expense of more specialised secondary mental health services
    2. Continued development of integrated services which jointly and holistically address mental, physical and social needs, especially for children, women in the perinatal period, people with learning disabilities and associated mental ill-health, people with serious mental illness, people suffering comorbid physical and mental illness, and older people with multiple physical and mental conditions and related social needs.
    3. Review and possible reversal of the ill-considered and austerity-driven dismantling of specialist mental health teams (eg for people in crisis, people with complex needs and personality disorders, assertive outreach for people with psychotic illnesses), or greatly enhanced resourcing of integrated Community Mental Health Teams.
    4. Further extension of psychological therapy services to provide more alternatives to medication, including increased provision of longer term psychotherapies for those with more complex and enduring mental health problems.
    5. Greatly enhanced services for children and young people with mental health problems (anxiety, depression, self-harm and eating disorders are increasingly prevalent), including collaborative mental health & wellbeing provision in schools and colleges, increased numbers of health visitors and school nurses, ready access to specialised mental health services (CAMHS), an increase in inpatient provision to avoid children and young people being admitted to hospital far from family and home, and specialist provision for eating disorders, post sexual abuse and other post-traumatic disorders, autistic spectrum disorders, Attention Deficit Hyperactivity Disorder, and drug abuse.
    6. Service development and further research for the identification and treatment of ill-health, and provision of integrated social care for older people with mental disorders or dementias, in domestic, community and residential (care and nursing home) settings.
    7. Substantial additional funding and improvement in health and social care services for children and adults with learning disabilities, including for autistic spectrum disorders.
    8. Urgent research and clinical intervention to reduce mortality rates for people with serious mental illness who still die 15-20 years before those without SMI.
    9. Urgent review of the escalating incidence of suicide and attempted suicide, urgent updating of suicide prevention strategies, and resources for rapid intervention and inter-agency collaboration following suicide attempts.
    10. Greatly improved cross-agency provision for people with acute mental health emergencies, including mental health / police interface services and crisis intervention services – including helping friends and families to cope. We should treat mental health crises with the same urgency and import as other medical crises.
    11. Reduction in the number of patients who are subject to Compulsory Treatment Orders, which have not been shown to benefit patients. This will require increased and improved in-patient treatment provision.
    12. Reversal of austerity-driven and counter-productive reductions in psychiatric in-patient bed numbers, including for children and young people.
    13. Comprehensive provision of integrated health and social care services for adults and children who have been exposed to significant traumatic experiences recently or in the past, including specialised psychological treatment services for those suffering from post-traumatic and related disorders.
    14. Urgent and rapid enhancement of mental illness diagnostic and treatment provision in the criminal justice system, especially in prisons for both adults and young people.
    15. Provision of comprehensive, country-wide mental health facilities with essential translation services for refugees and migrants, both in mainstream community services and in detention / removal centres.
    16. More research and sensitive provision for people who experience mental health problems as a result of exposure to stress in the workplace.
    17. Research on and more systematic approaches to evaluating the outcomes of treatments for the full range of mental health problems, including both common, episodic ill-health (eg anxiety and depressive disorders) and severe, enduring mental illnesses (eg schizophrenia, bipolar disorder).
    18. Resources for mental health services have been stretched to the point of dangerousness, so substantial additional funding, imaginative development of more integrated services, and persistent determination will be required to bring about the improvements and changes that are so urgently needed. Only a robust policy framework, freedom from repeated political interference, and ruthless commitment to delivery will achieve true ‘parity’ of esteem and funding for mental health.


    1. NHS Providers (2017) ‘The State of the NHS Provider Sector’

    2. NHS England (2016) ‘The Five Year Forward View for Mental Health’

    3. NHS England (2017) ‘Five Year Forward View for Mental Health: one year on’

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    Government austerity measures since 2010 have impacted healthcare across the UK.

    Holyrood is the administrator for NHS funds in Scotland but the Scottish Government has struggled to mitigate the impact of Westminster cuts.

    In the short-term they’ve had limited successes in keeping various healthcare plates spinning in the air — but with no clear end to cuts in sight, they might soon come crashing down.

    So here are three ways austerity is impacting health in Scotland and an overview of the stakeholders combating cuts.


    Prior to Scottish GDP figures being released in early July, the mainstream media was awash with warnings that the economy was on the brink of recession.

    Yet organs like the BBC were forced to flip their doomsday scripts overnight when it was revealed that GDP had grown by 0.8 per cent — outperforming the UK as a whole.

    But national statistics don’t reflect the challenges faced by those struggling regions where the economic picture isn’t so rosy.

    The downturn in the oil and gas industry has led to a 50 per cent rise in unemployment in North-East Scotland — with a serious knock-on effect on mental health.

    The Scottish Association of Mental Health’s Open Up campaign encourages residents in affected communities to openly discuss mental health problems — and helps them find sources of support.

    In terms of the employment rate the high level picture is healthy in Scotland —but figures are partially propped up by part-time roles and zero hour contracts.

    And workers in precarious employment are also facing rising rents — so it’s crucial to read between the lines with Scottish employment statistics.

    Mental health

    A report from the mental Welfare Commission in April revealed that even as austerity pressurised NHS mental health services, staff shortages in mixed psychiatric wards made female patients feel unsafe.

    The Scottish Government pledged to spend £300 million recruiting 800 new mental health staff over the next five years to plug the gap.

    This might present an opportunity for mental health nurses with diplomas to take online distance learning degrees that upgrade their skillsets for senior positions.

    But the NHS across the UK is haemorrhaging skilled overseas staff because of Brexit.

    Welfare reform

    The Welfare reform Acts of 2012 and 2016 have had a huge impact on some of Britain’s poorest and most vulnerable citizens.

    A UN report in late 2016 confirmed that these reforms show ‘grave or systematic violations of the rights of persons with disabilities’.

    And the study also highlighted the cultural shift that means disabled Britons and other disadvantaged groups are cast as scapegoats for Britain’s economic woes.

    Holyrood has spent £396 million over the past five years mitigating Westminster policies such as the bedroom tax — while their budget was slashed by £5 billion.

    And Westminster Welfare cuts mean another £2 billion has disappeared from the Scottish economy as those affected save the little cash they have, rather than spending in shops.

    Austerity has affected Scotland in similar ways to the rest of the nation. But it’s unclear whether the Scottish Government’s mitigation measures constitute a sticking plaster solution rather than a permanent cure.

    Have you experienced the effects of austerity in Scotland? Share your stories in the comments section.


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    Levels of rough sleeping have escalated rapidly in recently years, with reports of deaths on the street now increasingly common. The strong presence of homelessness-related commitments in all of the major UK political parties’ 2017 manifestos is welcome, but does little to dispel intense controversy over how best to intervene in this area.

    At the most basic level, responses to rough sleeping can be distinguished by whether they explicitly seek to alter or ‘control’ the behaviour of homeless people (‘interventionist’ responses) or not (non-interventionist responses). Interventionist responses include the use of ‘force’, such as arresting people for begging, rough sleeping or associated activities, or excluding them from particular areas (using civil orders like ASBOs or Public Space Protection Orders). They also include ‘coercive’ approaches which seek compliance via a ‘threat of deprivation’, for instance, by making access to accommodation conditional on signing up to a support plan. ‘Persuasive’ techniques, such as ‘motivational interviewing’ are core to the more ‘assertive’ forms of street outreach now used in many major cities.

    These interventionist approaches, and particularly ‘harder’ measures that employ force or coercion, are extremely controversial, often described as punitive or even as criminalisation. Some argue, however, that it is the non-interventionist stance of some soup kitchens, day centres, and traditional night shelters, generally run by faith-based organisations, that should be subject to moral censure, and that the ‘non-judgemental sanctuary’  that they offer can sustain damaging, even  life-threatening, patterns of behaviour among a highly vulnerable group of people.

    These polarised and emotive debates pose a challenge to policy-makers and service providers, and risk obscuring the need for cool-headed reflection in determining the most ethical approach. In a recent paper, Suzanne Fitzpatrick, Sarah Johnsen and I propose a four-point framework (inspired by Ruth Grant, a political philosopher at Duke University) to cut through this contested moral territory.

    First, does the intervention in question have a legitimate purpose? The idea that enforcement-based responses are pursued in defence of the aesthetic concerns and financial interests of wealthy gentrifiers has fuelled a great deal of the controversy that surrounds them. But in the UK at least, their adoption has also often been shown to be driven by the understandable concerns of ordinary local residents about health hazards like discarded needles or human waste in public spaces. The wellbeing of the homeless people targeted has also informed the Rough Sleepers Initiative of the 1990s as well as the more recent ‘No Second Night Out’ programme. Thus, despite widespread media hype, it is not the case that interventionist approaches necessarily reflect punitive intent on the part of politicians and policy-makers.

    Second, does the intervention allow for a voluntary response on the part of those targeted, therefore respecting their autonomy and capacity for self-determination? Here, non-interventionist approaches may seem at first glance to have the ethical advantage over more controlling interventions. However, the waters are substantially muddied by clear evidence of the highly constrained capacity of some individuals sleeping rough, especially those suffering from severe addiction and/or mental ill health, to act autonomously – that is, in pursuit of their own settled and authentic preferences. In such circumstances, a refusal to countenance ‘paternalistic’ interventions which seek to safeguard, restore or establish some basic level of personal autonomy for a vulnerable adult appears to us (as to James Gregory in his paper Engineering Compassion) “more like a moral abnegation… than respectful distance”.

    Third, what are the impacts of the intervention on the ‘character’ of those involved? There have been concerns, for instance, that commissioning practices that require faith-based organisations to engage in interventionist practices undermine their ethos of providing sanctuary and care unconditionally. Similar, homelessness organisations working with the police or UK Border Agency have been heavily criticised for ‘selling out’ and abandoning their core values. But we would argue that the material impact of homelessness interventions on their intended ‘beneficiaries’ should be given a much higher moral weighting than their impact on the character of the ‘benefactor’. An undue emphasis on the latter could be considered ethically dubious, even rather self-indulgent.

    This takes us to our fourth, and most important, moral consideration: what are the actual outcomes of the intervention in question? In particular, is it effective in improving the wellbeing of rough sleepers and, crucially, is it more effective than alternative (less controlling) methods? For example, while there is evidence that ASBOs have led to positive benefits for some street homeless people, acting as a ‘crisis point’ prompting engagement with support services, the use of such strong enforcement measure can only be justified as proportional when used as a last resort. The full range of consequences of any intervention must also be considered, including unintended negative effects. This would include, for example, displacing rough sleepers into more dangerous or isolated areas of the city.

    Equally, though, a key implication of this analysis is that the ‘tolerant’ approach taken by many soup runs, day centres and shelters ought to be subject to the same level of ethical scrutiny as interventionist responses. They should not be assumed to be morally unproblematic simply because terms like ‘unconditional acceptance’ sound innocuous. At a minimum, the possibility that tolerant approaches may inadvertently act to erode vulnerable people’s longer-term autonomy by sustaining them in street-based lifestyles must be taken seriously.

    These four criteria are offered as a route through what continues to be an extremely polarised debate on how to best respond to escalating levels of rough sleeping. A priori arguments, emotional intuitions, the (good) intentions of staff and volunteers, or even the views of current users of a service, do not suffice to settle these controversies. Instead, we should pursue responses that have the most significant and lasting positive impacts on those at risk on the streets.

    This was first published on the  British Politics and Policy blog

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    Recent figures show that only one third of workers who experienced a mental health problem in the last five years felt well-supported by their managers. Line managers routinely overestimate how well their workplace supports staff’s mental health and wellbeing, and less than a fifth of workers with mental health issues said they actually received the kind of support that would help them to remain in work.

    But why is this happening? Well, there’s a perception that those with mental health problems won’t be able to cope with workloads and the stresses and strains of the workday, which stops people discussing their health issues with anyone at work. There’s also an erroneous belief that those who suffer with mental health issues are simply using it as an excuse to get off work. There’s also a fear of the gossip, pressure and bad-treatment from colleagues who see an employee with mental health issues as being ‘deadwood’ to a company, all of which culminate to add to the stigma surrounding mental health.

    So what can employers do?

    One thing employers could do to de-stigmatise mental health issues in the workplace is to enable employees to remain in work with adjustments to their role. This is already a requirement under health and safety law, with employers being subject to a general obligation to take reasonable care for the health and safety of employees in the workplace, which means they have a duty towards people who may have mental health issues.

    Employers also have a legal duty not to discriminate because of a person’s disability (and in some cases, mental health issues can constitute a disability). However, it’s clear that there needs to be more flexibility than the law currently has the power to enforce, such as making an alteration to responsibilities where appropriate, or an adjustment to contracted hours or place of work. Both these solutions could go some way to closing the gap between duty and what happens in reality.

    And, while there’s no magic software solution or technological shortcut to improving a culture of understanding mental health or tackling mental health issues directly, investing in the right infrastructure could free up HR professionals to innovate and focus their attention to other things, including mental health. Employers ought to start investing in HR services on a larger scale, including the use of software to automate processes, as this could ensure HR professionals have time and capacity to focus their attention on matters as pressing as mental health.

    In addition, employers could reduce stigma around mental health by encouraging their employees to prioritise their own mental wellbeing, which means offering more sick days at full pay, preventing burn-out and achieving a healthy work-life balance. This might require better resourcing, a review to the number of sick days issued to staff, and a company culture of taking lunch breaks and leaving the office on time: a pipe dream for many, perhaps, but a major step towards looking after the mental health of all employees.

    Open communication is also required, as a lack of communication and understanding is perhaps the largest source of stigma around mental health in the workplace. This might mean holding learning lunches on the subject, organising training from external agencies, making support from mental health professionals available or even subsidising treatment such as counselling services.

    Furthermore, much of the stigma around mental health in the workplace could be reduced by enabling mangers to help others. This will require training managers so that they feel confident supporting their team, recognising mental health issues and knowing how to communicate confidently about them. Chris O’Sullivan, head of workplace mental health at the Mental Health Foundation even suggests encouraging those who have relevant experience to use it to support others.

    For example, he suggests that it might be valuable for managers to share their lived-experience of dealing with mental health issues. Whether or not this is a solution to de-stigmatising mental health depends on a manager’s willingness to share their experience, (and there certainly shouldn’t be any pressure placed on managers to do so), as respect for their privacy and facilitating the separation of their personal life from their work life is key. Managers should only be encouraged to share their personal experiences if they are genuinely willing to do so.

    Finally, employers need to work on the gap between policies regarding mental health and the actual everyday experiences of employees. Can a business truly be said to be aware, understanding and accommodating of mental health issues if their staff are routinely overworked, stressed, under-resourced or over-burdened? Is their sufficient provision for sick days, and would a mental health issue be challenged, sneered at or simply not accepted if someone called in sick for depression, anxiety or a similar mental health issue? 

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    Beyond Stressful: Why Anxiety and Addiction Are a Dangerous Combination

    Most people experience anxiety from time to time. Many individuals living in the UK, however, experience frequent, unceasing forms of anxiety. These symptoms make it more difficult for some individuals to live fulfilling, productive lives.

    According to a 2013 study published in the Journal of Psychopharmacology, more than 8 million cases of anxiety disorders were reported in the UK. Managing anxiety is possible with treatment, but this task becomes significantly more difficult when an anxiety patient is also struggling with drug or alcohol addiction.

    Anxiety and addiction are major health risks on their own, and both become considerably more dangerous when co-occurring with another disorder. Data collected by the National Health Services suggest that up to 50 per cent of people facing mental health problems also have a substance use disorder.

    Considering that anxiety is the most prevalent mental health problem in the world, it is safe to say that the combination of anxiety and addiction represents a common dual diagnosis.

    When Anxiety and Addiction Form a Pair

    Anxiety and substance use form a problematic pair for individuals trying to manage both disorders at the same time. It is not unusual for the symptoms of a substance use disorder to exacerbate the symptoms of anxiety. Likewise, those who see relief from their mental health issues via substance abuse will find that their anxiety symptoms grow more unmanageable when they are sober.

    This vicious cycle underscores just how dangerous this combination of mental health issues can be. Examples of co-occurring substance use and anxiety disorders include:

    • A post-traumatic stress disorder patient who uses alcohol to lesson psychological trauma and experiences more severe depression symptoms
    • A person with a social phobia uses prescription pills to lessen his or her inhibitions in social settings, but finds that the phobia symptoms get worse when sober
    • An obsessive-compulsive disorder patient begins using marijuana to ease his or her compulsions and develops a new obsession with the physical act of smoking

    The Need for Dual Diagnosis Treatment

    The term “dual diagnosis” refers to any time a patient is afflicted with more than one mental disorder simultaneously. These patients are particularly at risk because the symptoms of one disorder typically interfere with the treatment of the other. Patients dealing with co-occurring anxiety and substance use disorders are a prime example of this phenomenon.

    A person with a social phobia, for example, may find it difficult to participate in group therapy for his or her addiction. Similarly, a person who is going through withdrawal symptoms to overcome addiction may be more likely to experience a panic attack and feel the urge to continue using. These scenarios emphasize the need for specialized treatment that addresses the root of both disorders.

    Solving Anxiety and Addiction

    What’s the best way to treat co-occurring addiction and anxiety? Today, most experts believe that the most effective approach is to treat these conditions simultaneously. That’s why leading treatment facilities hire psychiatric professionals as well as medical doctors to join their staff. With both types of expertise available in house, these treatment centers can develop personalized recovery strategies that address the symptoms of both mental disorders.

    Considering the massive overlap of individuals with anxiety disorders and addiction, it would not be surprising if dual diagnosis treatment becomes the default treatment approach for these co-occurring disorders. In the meantime, dual diagnosis patients and their families must be diligent in finding a treatment center that can serve their needs.


    Click to access dualdiagnosis.pdf

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