The ESA labyrinth

Advocacy for people with mental health conditions is set to become a growth industry for 2012. The Benefits Scandal  by Kaliya Franklin and Sue Marsh shows how benefits for eligible individuals are being made harder and harder to access. A short extract on ESA (Employment Support Allowance) follows:

When it was initially proposed, one of the ideas of the Employment Support Allowance was that disabled and sick people should be helped and supported to work if they wished to do so. 

This was a valid and popular idea. Many sick or disabled people would indeed love to work if there was work that they could do. 


But in its present form the ESA is failing: it simply presents the claimant with a series of dead ends, backed up by a whole raft of sanctions and means tests that negate any realistic chance of success. It takes little account of the limitations of individual conditions, or the barriers to work that someone with a fluctuating or mental health condition may face. 

The capability tests that are applied to claimants are simply unfit for purpose. Currently around 40 per cent of cases go to appeal, and of these 40 per cent succeed in overturning the original decision, a figure that rises to 70 per cent for those with representation. 

Mental health and employment

Mark Brown, editor of One-in-Four magazine has written an excellent feature of mental health and employment.  It is one of the few articles I have come across that speaks common sense on the role of work in mental health recovery.  Mark acknowledges that the journey back into work from secondary or primary care is not straightforward and that employment is not a panacea in itself.  As Mark says:

'For me, the most important thing to remember when discussing work and recovery is that work itself isn’t a magic four letter word; it’s everything that someone gains from being in work that is important'.

Mark Brown is the editor of One in Four magazine
For the full article:
http://www.oneinfourmag.org/index.php/mental-health-and-work-not-a-magic-four-letter-word/

One in Four magazine

One in Four magazine has an excellent article about stigma.  Catherine Amey examines stigma from both sides.  The positive side of mental health stigma being challenged and the less positive side where an over-emphasis on stigma might be harmful for some people.

The One in Four project was conceived by Mark Brown and shaped by his personal experience of mental health difficulty.

The vision was to produce a magazine that inspires people with mental health difficulties to get the best out of life while challenging stereotypes and spreading information that would help everyone to understand mental health difficulty better.

Working with his colleagues at Social Spider CIC Mark developed One in Four as a magazine which approached mental health difficulty in a new way and challenged the stigma that people with mental health difficulties can feel; an aspirational lifestyle magazine covering common life experiences, ambitions and challenges in a way that is readable and relevant to all.

In December 2006, Social Spider secured funding from The Charlie Waller Memorial Trust and South London and Maudsley NHS Foundation Trust Charitable Funds to produce a pilot issue of One in Four to be made available free through community outlets such as GPs’ surgeries, public libraries and places of treatment.

10,000 copies were distributed and the magazine was downloaded 7,000 times from this website – an estimated total readership of around 40,000. Feedback from online and offline surveys and focus groups was overwhelmingly positive with repeated acknowledgement of the magazine’s high production values; 90% said they wanted to read future issues and 75% gave it an approval rating better than 8/10.

As a result of this response, Social Spider has sought funding and developed partnerships and trading activities around the project to enable One in Four to launch as a regular quarterly magazine distributed throughout England.

There is currently no other independent, professionally produced magazine in the UK which is written for people with mental health difficulties and is written by them. Social Spider believes in the potential for One in Four to bring about positive change in the lives of its core audience, their friends, family and carers.

Aside from the money raised through sales of the magazine and other services One in Four is currently supported by Comic Relief, The Charlie Waller Memorial Trust, The South London and Maudsley NHS Foundation Trust Charitable Funds and the Wates Foundation.

Catherine Amey’s book 'Psychosis through My Eyes: A Personal and Professional Journey'  is scheduled to be available as an ebook in September 2011 from Chipmunka Publishing.

Is anti-stigma the new stigma?

The 'Time to Change' campaign challenges stigma and discrimination against people with mental health conditions. Time to Change is helping groups and individuals organise activities which actively cooperate in challenging discriminatory attitudes and behaviours.

Challenging discrimination is achieved primarily through engaging in mainstream as a contributor, a consumer or a provider. Many people with mental health conditions access mainstream activities, making their own choices as to whether to disclose or not. The greatest impact in challenging mainstream can be achieved by prioritising individual goals and aspirations. Support is also available to access mainstream from mental health organisations and bridge builders or through personalisation and direct payments.

'Time to Change' seems to insist that all people with mental health conditions wish to disclose as part of their eligibility for mainstream life. In a recent campaign video the broadcaster and service user Stephen Fry asserts that stigma and the attitudes of society in general are the main roadblocks that hinder the self-development of people with mental health conditions.

But many individuals with mental health diagnoses are accessing mainstream life without stigma, whether they choose to disclose or not. Disclosure is really up to the individual and far from discouraging service users to use mainstream, many organisations are open to all and are accessed by people with mental health conditions every day of the week. These are not simply voluntary organisations or groups limited to the health or charity sectors. These are consumer providers of all kinds - art galleries, libraries, recording studios, performance venues, gyms, sports centres, retail outlets and many more. To assert these these organisations are discriminating simply isn't fair on these groups, nor is it a realistic assessment.

Where people with mental health conditions may lose out is in having the initial confidence to set on the journey back to mainstream. This is particularly true of those who have been in secondary care and who may have become habituated to the life that Pat Deegan calls 'a career in mental health'. Dr. Deegan is referring to the lack of hope, aspiration and goals that can set in with hospitalisation or a long-term condition.

People who play football who happen to have mental health conditions are footballers. They aren't required to be 'positive mental health footballers'. People who play guitar who happen to have mental health conditions are guitarists, not mental health guitarists. People who are arts tutors who have a mental health condition are arts tutors. By continuing to tag mental health on mainstream activities and aspirations there is a danger of recycling stigma and not allowing people to move into valued social roles.

Could anti-stigma be the new stigma?

Ian Springham - Portrait of a talented artist

One of the great pluses of working for a mainstream organisation like 'Imagine' is the opportunity it gives to meet and work with a diverse range of talented people.  The artist and painter Ian Springham has tutored in mixed media for Imagine.  He also co-organised an exhibition at Wimbledon Library gallery.  This is Ian's story:

'In my 30s, I experienced a series of breakdowns far beyond anything thitherto experienced. It felt as though the entire Universe had exploded, the echoes of which long reverberated in my psyche.

Whilst trying to find appropriate help, I had to deal with an ever-more bewildering set of diagnoses, as I revealed more of my inner world. My labelling starting with Panic Disorder and went through to Borderline Personality Disorder and beyond ..

Despite this admirable list, there seemed to be little means of help available and whilst awaiting therapy, as well as researching and joining groups online such as BorderlineUK and PersonalityPlus, I joined the Service Users Network. However, what I really needed was one-on-one psychotherapy. After incessant badgering from my wife, 13 psychotherapeutic sessions became available. Despite confirming many of my worst fears, they were over before I could start to stuff the released demons back into their respective bottles.

Further pressures from my wife brought about a 40-week series of sessions with an esteemed psychotherapist - such was the complexity of the presenting disorders. Having reached a greater understanding and acceptance of myself, there also being no more therapy available on the NHS, I set upon a haphazard course through Alcoholics Anonymous, Croydon College, and Merton Adult Education’s art classes for people similarly troubled.

There was no stopping me. I blossomed through art and Imagine Mental Health eventually invited me to run their art sessions. This was the outwardly visible start of rebuilding my life, as I found I could use my previously untapped empathy and experiences to help others. Classes and exhibitions of artwork followed, giving confidence in both mine and others’ recovery. Finally I’d found a way through.

Later the MACS drug & alcohol project further extended belief in my artistic and mentoring skills, and lead to me volunteering for the online forum that Rethink Mental Illness provides. I put longstanding IT skills and online experience developed as coping mechanisms, to better and wider use. RethinkTalk is an online community for everyone affected by severe mental illness to exchange ideas, opinions, artwork, and support. My roles there as moderator, guide, advocate, activist, friend, mordant artist, and occasional wit, have hopefully also helped others explore their situations in a safer, more supportive environment.'
Ian Springham

Exposure to mainstream life

Mental health service users who live in residential care settings are often in danger of never being able to realise mainstream goals.  For various reasons it turns out that the initial exposure to mainstream life is the key factor in determining an individual's further progress into that milieu.

Residential care covers a range of bases.  It could be a residential home or a family setting, even the setting of a marriage or a personal relationship.  Carers and support workers do not always have their charges' independence as a key priority.  Sometimes carers or family members derive more support for themselves by living or being with the 'cared-for' member than vice versa.  Even staff within the clinical teams are often geared to providing support at the expense of encouraging mainstream development. What this can lead to is a form of unnecessary and intrusive over-protectiveness.

The results of enabling people to access mainstream are frequently nothing short of amazing. When this access is based entirely on clients' own choices the results can become formidable.    

Obliquity and mental health

Formulated by economic theorist and author John Kay, obliquity is the notion that complex goals are often best achieved indirectly. As Kay puts it 'happiness is the product of fulfilment in work and private life, not the repetition of pleasurable actions, so happiness is not achieved by pursuing it'.

Kay is hailed widely as a perceptive business and organisational guru, but his ideas have a great deal of relevance in the mental health field.

Kay is very strong on the question of goals and defining business and personal objectives. However his take is interesting as he does not have a straightforward linear viewpoint.

'We find out about the real nature of our goals in the process of accomplishing them, and our understanding of the complex structures of personal relationships or business organisations is necessarily incomplete', Kay writes.

John Kay underlines the importance of goals and goal-setting, which is commonplace in most business and personal development thinking. But he emphasises that even when we set clear goals, we only 'find out about the real nature of our goals in the process of accomplishing them'.

Nothing could be more true when this perception is applied to mental health, recovery and mainstream.As a social inclusion bridge builder, I am employed to help enable clients set clear goals and prioritise a personal route into and through the mainstream environment. But even when a client has prioritised one specific pathway, it can sometimes be the case that this will not be the area of mainstream that he or she will end up pursuing.

I have clients who have prioritised music or the arts but who soon find a place elsewhere - in sports, volunteering or employment, for example.

It used to be somewhat discouraging to find that clients were not engaging in their originally prioritised mainstream domains. Now I check with other members of the bridge building team and find that many of my original referrals are now active in other areas.

Obliquity in action!

As John Kay puts it: 'the paradox of obliquity is all around us'.

No symptoms, no problems

“Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.” Shepherd, Boardman and Slade 2008.

There are implications for any mental health recovery programme if it is to take place regardless of 'ongoing symptoms or problems'. Firstly, it requires that the recovery programme is not determined solely by an individual's clinical diagnosis. Instead, it must be determined by a person identifying what he or she needs to build a life that is 'meaningful and satisfying'.

An appropriate service and environment in which this identification can take place needs to be in place to help signpost the journey towards invidual goals and aspirations. Fortunately, there are strategies built in to the care pathway that can enable individuals to identify personal goals and locate the sites in mainstream where hopes and goals can be realised. Whether these services are commissioned locally and regionally in specific areas is another matter.

It is important that aspirational settings are embedded in mainstream because individual goals are not fulfilled in clinical environments, although they may be identified therein. It is in mainstream where each and every one of us makes the path to achieving our goals. Mainstream is where we live, work, learn, create, exercise, develop and grow. Mainstream venues are the sites where these developments can take place. Sites that include the arts, sports, education, retailing, volunteering, befriending, family, friends, faith and employment. It is broadly one or more of these areas that an individual will identify as useful to his or her developmental choices.

When this person-centred practice is backed up by a team that can help direct an individual to the appropriate mainstream setting, then a recovery programme can start in earnest. It may well be that other settings have helped or continue to help in achieving this - settings such as day services and what used to be referred to as 'sheltered' activities or community projects. The clinical teams also - assertive outreach, O.T.'s and key workers all contribute to client independence.

It is important that the initial conversation about an individual's mainstream goals and aspirations takes place in a mainstream setting. This may well be an individual's first re-introduction to the mainstream world after what could have been years of semi-institutional or supported environments. It is extremely unlikely that the practical hope of achieving mainstream is communicated in a hospital consulting room or even in an individual's own home. Those areas are associated with support, care and treatment. Mainstream recovery has to go beyond these boundaries.

So what sort of team can best support an individual when it's not support he or she is requesting but access to goals and self-development? I would argue that this needs to be provided by a bridge-building team, each member equipped to identify the mainstream venues appropriate to the goals the client has identified.

Regular readers of this blog will know that I am an arts and faith bridge builder based in south London. Readers will also know that I work directly with people referred from secondary care, that is people with what are called 'severe and enduring' mental health diagnoses. I work with colleagues who are all trained in identifying the mainstream areas appropriate to their bridge building roles. The employment advisor must know about mainstream employment, the sports bridge builder about sports venues, the arts bridge builder must know about the arts locally and regionally.

Mainstream is often achieved indirectly and obliquely. For example, a client who has identified music as a mainstream goal may not go on to achieve in that field or may change their mind about music as a choice in their recovery. This can be disappointing for me as arts bridge builder, but it is often the case that these individuals benefit immensely from other aspects of mainstream that the team is able to offer. I frequently find that some clients who have not engaged through the arts are nonetheless following mainstream goals via the befriending service or through volunteering and sports activities.

Conversely, it can be the case that a client who has been signposted to a music outlet in mainstream, goes on to achieve goals that go far beyond the initial contact with a music studio or rehearsal room that he or she has requested. Such clients can and do develop employment and self-employment pathways or go on to further and higher education opportunities. These goals have been achieved through the initial contact with mainstream and couldn't have been realised any other way. Mainstream itself will often generate these opportunities for the client independently of the bridge building service.

Because bridge building has the strength to enable an 'oblique' approach, there can be limitless opportunities for motivated clients choosing their recovery pathway. Even a relapse can only hold up rather than destroy the process. The confidence and skill levels that clients develop in mainstream enhance growth into further mainstream activities and domains.

Imagine Mainstream studio collaboration at Crown Lane Morden

Mainstream in 2012

The future of the mainstream approach in mental health recovery is bleak.  Once pioneered as the most radical yet realistic approach to the care pathway, mainstream has now been side-lined and pushed into a corner.

The thinking behind mainstream in mental health is simple.  Linking up individuals with mainstream areas of their own choice as part of recovery.  These areas or 'social domains' cover a wide spectrum: the arts, employment, volunteering, sport and healthy living, faith, worship or spirituality, employment, self-employment, education and business.

In 2012, the cuts in mental health provision are deep and across the board.  Employment is touted as a be-all and end-all yet employment often only happens through a gradual re-introduction to mainstream living .  This is especially true for people who are in secondary mental health care with a diagnosis of 'severe and enduring' conditions.

The outcomes that have been attained by individuals who have been referred or self-referred to a mainstream service are often formidable.  Access to mainstream arts providers such as music recording studios, visual arts courses or creative writing workshops have led to individuals succeeding in employment, self-employment, higher education and collaborative enterprises with their peers.

The mainstream approach goes far beyond therapies and this blog contains many examples of its success.

Mainstream is based on recovery as opposed a 'cure'.  It is also based on the individual claiming his or her right to mainstream living along with everyone else.

The opportunity to access mainstream on his or her own terms is not denied to an individual with a 'severe and enduring' mental health diagnosis. Mainstream can be highly supportive of clients' individual aspirations and self-development. Sometimes this encouragement comes directly from the mainstream outlet itself rather than being dictated by carers, statutory services or voluntary agencies. What can be denied and often is, is the opportunity to access the opportunities in the first place.

In many cases, an individual with a 'severe and enduring' mental health diagnosis will only have the chance to access a mainstream activity if it is built in to his or her care pathway and recovery plan.  The professionals who can help signpost people to such activities will be skilled in allowing individuals to identify personal goals and aspirations.  They will also need skills in knowing exactly where the mainstream sites are where an individual can develop and pursue his or her aspirations.   Linking someone up with a mainstream activity of his or her own choice allows that mainstream venue to provide exactly what it is already providing for its clients, users and consumers. 

The client with a mental health diagnosis will be treated no differently from anyone else, unless he or she has specificied particular adjustments.  That too is part of person-centred planning, with individuals free to disclose or not as they deem fit.

There are sound reasons for mainstream being a lot less discriminatory and stigmatizing than it can be portrayed. Mainstream allows individuals to access services as consumers with consumer rights. If someone with a mental health diagnosis freely chooses to develop his or her aspirations in a mainstream environment, there is no good reason why that person should be denied any of the services that particular venue may provide. The client is accessing mainstream as a consumer of that service, not as a 'diagnosis'.

Once a firm relationship with mainstream has been established, there are multiple ways that mainstream finds to continue to develop individual hopes, dreams and aspirations. I have clients who have found employment through accessing music by rehearsing regularly in a mainstream recording studio. Others have opted to join higher and further education outlets to progress with their dream. Yet others have become volunteers in an environment they enjoy. This has not happened because I have requested the venue to provide employment for my clients Far from it - the venue itself often instigates the process or helps provide the signposting. In many cases this can lead an individual towards a working role in the environment where he or she happens to feel most fulfilled.

This is the viral effect of mainstream

John sings original song 'Revival Day' live at London's Jamboree Club

A Career in Mental Health?

Care and support are not the only models or frameworks for mental health recovery. The establishing or re-establishing of what Dr. Pat Deegan refers to as 'valued social roles' can be held back by a mental health system that often encourages the client to choose 'a career in mental health' (Pat Deegan).

A career in mental health means living longterm on benefits and longterm marginalisation from mainstream life. A career in mental health will identify symptoms, diagnoses, medication and team support but will often leave out aspirations, goals, priorities.

Where access to mainstream is encouraged, it can often be through projects or programmes which take place in special settings or are designed for people with mental health conditions. So the marginalisation continues.

A genuine return to mainstream can only take place in mainstream. This is where the role of the life coach or bridge builder comes in. A client who has worked with a mainstream bridge builder identifies goals and priorities for him or herself. It is the bridge builder's job to signpost or link the client up with mainstream venues appropriate to the client's life choices. The amount of support a client may request from there on is determined only by the client not by the life coach.

Music production in mainstream

Music production courses in Morden London are enabling Imagine clients to make a return to mainstream life through things they feel passionate about.

John Vanek sings William Blake 'Hear the Voice of the Bard'

Building a meaningful life

“Recovery is about building a meaningful and satisfying life, as defined by the person themselves, whether or not there are ongoing or recurring symptoms or problems.”  Shepherd, Boardman and Slade 2008.

There are implications for any mental health recovery programme if it is to take place regardless of  'ongoing symptoms or problems'.  Firstly, it requires that the recovery programme is not determined solely by an individual's clinical diagnosis. Instead, it  must be determined by a person identifying what he or she  needs to build a life that is 'meaningful and satisfying'.

An appropriate service and environment in which this identification can take place needs to be in place to help signpost the journey towards invidual goals and aspirations. Fortunately, there are strategies built in to the care pathway that can enable individuals to identify personal goals and locate the sites in mainstream where hopes and goals can be realised.  Whether these services are commissioned locally and regionally in specific areas is another matter.

It is important that aspirational settings are embedded in mainstream because individual goals are not fulfilled in clinical environments, although they may be identified therein.  It is in mainstream where each and every one of us makes the path to achieving our goals.  Mainstream is where we live, work, learn, create, exercise, develop and grow.  Mainstream venues are the sites where these developments can take place.  Sites that include the arts, sports, education, retailing, volunteering, befriending, family, friends, faith and employment.  It is broadly one or more of these areas that an individual will identify as useful to his or her developmental choices.

When this person-centred practice is backed up by a team that can help direct an individual to the appropriate mainstream setting, then a recovery programme can start in earnest.  It may well be that other settings have helped or continue to help in achieving this - settings such as day services and what used to be referred to as  'sheltered' activities or community projects.  The clinical teams also - assertive outreach, O.T.'s and key workers all contribute to client independence.

It is important that the initial conversation about an individual's mainstream goals and aspirations takes place in a mainstream setting.  This may well be an individual's first re-introduction to the mainstream world after what could have been years of semi-institutional or supported environments.   It is extremely unlikely that the practical hope of achieving mainstream is communicated in a hospital consulting room or even in an individual's own home.  Those areas are associated with support, care and treatment.   Mainstream recovery has to go beyond these boundaries.

So what sort of team can best support an individual when it's not support he or she is requesting but access to goals and self-development?  I would argue that this needs to be provided by a bridge-building team, each member equipped to identify the mainstream venues appropriate to the goals the client has identified.

Regular readers of this blog will know that I am an arts and faith bridge builder based in south London.

Readers will also know that I work directly with people referred from secondary care, that is people with what are called 'severe and enduring' mental health diagnoses.  I work with colleagues who are all trained in identifying the mainstream areas appropriate to their bridge building roles.  The employment advisor must know about mainstream employment, the sports bridge builder about sports venues, the arts bridge builder must know about the arts locally and regionally.

Mainstream is often achieved indirectly and obliquely.  For example, a client who has identified music as a mainstream goal may not go on to achieve in that field or may change their mind about music as a choice in their recovery.  This can be disappointing for me as arts bridge builder, but it is often the case that these individuals benefit immensely from other aspects of mainstream that the team is able to offer.  I frequently find that some clients who have not engaged through the arts are nonetheless following mainstream goals via the befriending service or through volunteering and sports activities.

Conversely, it can be the case that a client who has been signposted to a music outlet in mainstream, goes on to  achieve goals that go far beyond the initial contact with a music studio or rehearsal room that he or she has requested.  Such clients can and do develop employment and self-employment pathways or go on to further and higher education opportunities.  These goals have been achieved through the initial contact with mainstream and couldn't have been realised any other way.  Mainstream itself will often generate these opportunities for the client independently of the bridge building service.

Because bridge building has the strength to enable an 'oblique' approach, there can be limitless opportunities for motivated clients choosing their recovery pathway.  Even a relapse can only hold up rather than destroy the process.  There are confidence and skill levels that clients develop in mainstream that will stand them in good stead.

Music Production course at Crown Lane Studio London

The viral effect of mainstream

Things can happen when a client with a mental health condition is allowed the opportunity to access mainstream on his or her own terms. Mainstream can be highly supportive of clients' individual aspirations and self-development. Sometimes this encouragement comes directly from the mainstream outlet itself rather than being dictated by carers, statutory services or voluntary agencies. 

There are sound reasons for this.  Mainstream allows individuals to access services as consumers with consumer rights.  If someone with a mental health diagnosis freely chooses to develop his or her aspirations in a mainstream environment, there is no good reason why that person should be denied any of the services that particular venue may provide.  The client is accessing mainstream as a consumer of that service, not as a 'diagnosis'. 

Once a firm relationship with mainstream has been established, there are multiple ways that mainstream finds to continue to develop individual hopes, dreams and aspirations.  I have clients who have found employment through accessing music by rehearsing regularly in a mainstream recording studio.  Others have opted to join higher and further education outlets to progress with their dream.  Yet others have become volunteers in an environment they enjoy. This has not happened because I have requested the venue to provide employment for my clients  Far from it, the venue itself often instigates the process or helps provide the signposting.   In many cases this can lead an individual towards a working role in the environment where he or she happens to feel most fulfilled.

This is the viral effect of mainstream

Obliquity in Mental Health

Formulated by economic theorist and author John Kay, obliquity is the notion that complex goals are often best achieved indirectly. As Kay puts it 'happiness is the product of fulfilment in work and private life, not the repetition of pleasurable actions, so happiness is not achieved by pursuing it'.

Kay is hailed widely as a perceptive business and organisational guru, but his ideas have a great deal of relevance in the mental health field.

Kay is very strong on the question of goals and defining business and personal objectives. However his take is interesting as he does not have a straightforward linear viewpoint.

'We find out about the real nature of our goals in the process of accomplishing them, and our understanding of the complex structures of personal relationships or business organisations is necessarily incomplete', Kay writes.

John Kay underlines the importance of goals and goal-setting, which is commonplace in most business and personal development thinking. But he emphasises that even when we set clear goals, we only 'find out about the real nature of our goals in the process of accomplishing them'.

Nothing could be more true when this perception is applied to mental health, recovery and mainstream.

As a social inclusion bridge builder, I am employed to help enable clients set clear goals and prioritise a personal route into and through the mainstream environment. But even when a client has prioritised one specific pathway, it can sometimes be the case that this will not be the area of mainstream that he or she will end up pursuing.

I have clients who have prioritised music or the arts but who soon find a place elsewhere - in sports, volunteering or employment, for example.

It used to be somewhat discouraging to find that clients were not engaging in their originally prioritised mainstream domains. Now I check with other members of the bridge building team and find that many of my original referrals are now active in other areas.

Obliquity in action!

As John Kay puts it: 'the paradox of obliquity is all around us'.

The role of the bridge builder

Bridge building is a strategy developed in the late 1990s and early 2000s.  Designed to promote social inclusion for groups that might otherwise be marginalised, bridge building has been used to immense effect in the mental health field.  Bridge building is particularly useful for people who suffer or who are in recovery from severe and enduring mental health conditions.

The role of the bridge builder is very simple.  It is to help facilitate access to mainstream environments for individuals, based entirely on their own personal choices.  The original social inclusion think-tanks were set up by the (then) office of the deputy prime minister.  Nine key social domains were identified as key to individual development.  However, it is not expected that every individual would be expected to access every single domain, nor would they wish to.  The key areas include employment, arts & culture, faith and cultural communities, education & training, volunteering, befriending, sports and wellbeing.  There are other domains as well, such as friends and family and statutory services. 

Within these contexts, a bridge building team can be set up, working in mainstream with referrals from other agencies particularly NHS and social services.  It is crucial that the organisation that is commissioned to carry out mainstream is itself embedded in a mainstream environment or conducts its interactions with clients in the big wide world, rather than in a clinical setting.  It is the only way that a conversation with a client about their hopes and aspirations can be realistic and genuine. These approaches are entirely in line with the way mainstream was envisaged as a key part of the care pathway and an alternative to what Dr. Pat Deegan has aptly described as 'a career in mental health'.

What the heck is person-centred planning?

Person centred planning is a collection of tools and approaches based upon a set of shared values that can be used to plan with a person - not for them . These tools can be used to help the person think about what is important in their lives now and also to think about what would make a good future. Planning should build the person's circle of support and involve all the people who are important in that person's life.

It was developed as a way of enabling people - children and adults - to move out of special segregated places schools, hospital and institutionals into mainstream life - schools and communities.

Person Centred Planning is built on the values of inclusion and looks at what support a person needs to be included and involved in their community. Person centred approaches offer an alternative to traditional types of planning which are based upon the medical model of disability and which are set up to assess need, allocate services and make descisions for people. Person centred planning is rooted in the social model and aims to empower people who have traditionally been disempowered by 'specialist' or segregated services by handing power and control back to them.

For mental health services where the return to mainstream is a key component of the care pathway, person-centred approaches are essential.  It's not solely the person-centred  approach which is vital but equally, the settings in which those approaches take place.  The client who has requested access to a mainstream social domain of their own choosing has every right to be introduced directly to that setting.

A conversation about mainstream access should take place in the appropriate mainstream venue.  A client who has requested access to a football group as a player has a right to be introduced to that team.

A client who has requested access to a recording studio for rehearsal his or her music, has the right to be introduced to a mainstream recording studio.  A client who has expressed a desire to access a higher or adult education course has the right to be introduced to the venue of their choosing.  All of this is entirely in line with the philosophy and practice of mainstream recovery as an 'alternative to traditional types of planning which are based upon the medical model of disability'.

Roadblocks in Mainstream

For many years mainstream has been perceived and practised as a key component of the care pathway in mental health provision.

At several stages of the pathway into mainstream there are roadblocks.  These can occur from the individual client, from services, even from families and carers. An individual can feel apprehensive of stepping over the threshold into mainstream activities.  This can be for a variety of reasons, ranging from self-stigma or from being so long in the mental health system that independence seems a very distant option.  Contrary to some current opinion, it is not stigma from mainstream society that creates the main roadblock.

Dr. Pat Deegan's belief is that too often the health system can encourage what she calls 'a career in mental health' and nothing else.  This viewpoint is based on her experience as a service user and it still holds true.

A great deal is being achieved by service users themselves to challenge the roadblocks.  This is particularly true where creative and personalised use of direct payments and individual budgets have really taken off around the UK.  It hasn't happened everywhere but some immensely inspiring stories and testimonials can be viewed at the NMHDU website. 

Creative use of direct payments in mental health recovery is currently sporadic.  The intention was that this should increase towards full implementation of the personalisation programme.  Invididual budgets were scheduled to become the engine for much healthcare practice all over the UK by 2013.  However, this is now completely overshadowed and possibly lost permanently, in the thrust towards GP consortia and budget management.

Alongside the sudden disappearance of direct payments is the disappearing access to therapies, both for primary and secondary care patients.  Secondary care clients have often lost out in the therapies scenario for a variety of reasons.  But clients in primary care are still entitled to a reasonably smooth road to psychological therapies.  Entitlement does not ensure that those therapy services are available and in practice these too are disappearing along with personalisation and individual budgets.

Of course any client is free to fund their own mainstream recovery pathway and many do. The outcomes in this area alone (south-west London) have often been formidable.  A composer who has funded her own recordings and launches now has self-employment through her music.  Many are those who have accessed adult education courses and further training.  Individuals have re-accessed faith venues which they had previously felt unable to enter for many years. 

Not all these initiatives require direct payments - anyway those have now dried up.  Many activities are free to access or funded by individual clients from their own pockets.  Where direct payment has been needed it has often made the crucial difference. 

Third-sector organisations also do great work in promoting access to mainstream through a variety of initiatives.  'Emergence' is an arts group run by and for service users who are also visual artists.  In London and around the country 'Emergence' has pioneered access to visual arts as well as giving a platform for creativity and exhibition spaces for artists with personality disorder. 

'Imagine' in south west London and Surrey also promotes a variety of arts opportunities including music production and visual arts.  These are open to service users but take place in mainstream settings.

Mainstream environments have their own health, safety and insurance policies.  As a consumer, the service user to entitled to the protection of these policies along with every other mainstream customer and client.

Libraries and mental health

Shaun Bailey, an ambassador for the big society project and a former Conservative prospective candidate, has asserted that local councils are closing public libraries because they are "not being used". (Radio 4 'Today 'programme).

Where has he been?  Over the last three years local libraries have become a major resource for mental health in the south-west London borough where I work as a bridge builder.  The libraries are being used as never before.

As part of the movement to mainstream independence, mental health provider Imagine has moved its day centre services into the local libraries.  Not only does this dramatically decrease the marginalisation of people with mental health challenges but it also enables more access for more people.  Libraries in their role as community providers have never been more useful and more utilised.  The stigma of mental ill-health is itself sidelined when service users access libraries along with the rest of the general public.  That's mainstream.

Libraries managers and staff were amongst the first to sign up for mental health awareness training when it was offered in the borough. 

I count libraries are amongst the most socially inclusive environments in contemporary community life.  My client meetings often take place in the local library.  Meeting in a library is one of the best ways to start the conversation about mainstream in a non-clinical setting. 

Mainstream can only take place in and from mainstream.  Libraries are at the forefront of the practice of inclusion.

Care & support can hinder recovery - revisited

Care and support are not the only models or frameworks for mental health recovery. The establishing or re-establishing of what Dr. Pat Deegan refers to as 'valued social roles' can be held back by a mental health system that often encourages the client to choose 'a career in mental health' (Pat Deegan).

A career in mental health means living longterm on benefits and longterm marginalisation from mainstream life. A career in mental health will identify symptoms, diagnoses, medication and team support but will often leave out aspirations, goals, priorities.

Where access to mainstream is encouraged, it can often be through projects or programmes which take place in special settings or are designed for people with mental health conditions. So the marginalisation continues.

Where the retardation of an individual's access to mainstream is most acutely felt often lies conversely in the areas where there is the most 'support'.  Nowhere is this more clearly visible  than in secondary residential care. 

Whereas the main thrust of residential care in mental health is on clients' independence, the system often works to block individual progress.  Mental health residential teams expend a lot of effort and do a lot of work encouraging their clients to seek independent opportunities in mainstream life.  Unfortunately, the desire to do these activites may not derive from the client him or herself and the contact with mainstream is delayed, deferred or postponed sometimes indefinitely. 

Where a client is goaded into mainstream in this way, he or she will sometime be bussed or  taxied in to the mainstream venue, accompanied by a key worker.  But no amount of buses, taxis or key workers can replace the simple presence of individual personal motivation. 

In secondary care, a  client's last-minute postponing of the scheduled meeting with mainstream is also commonplace - often postponing three, four or five times.  The assumption by services that an able-bodied physically-well individual should need to be accompanied to a local venue by a carer or key worker at all times, seems to me profoundly patronising.

A genuine return to mainstream can only take place in mainstream. This is where the role of the bridge builder comes in. A client who has worked with a mainstream bridge builder identifies goals and priorities for him or herself. It is the bridge builder's job to signpost or link the client up with mainstream venues appropriate to the client's life choices. The amount of support a client may request from there on is determined only by the client.

Clinical and social models of care

In the mental health field, it has long been accepted that clinical and social models of care go hand-in-hand.  Doing more than simply addressing clinical symptoms is a requirement of the care pathway. 

People who have experienced severe and enduring mental health conditions currently have access to a spectrum of professionals.  These range from the psychiatrist, the community mental health nurse, assertive outreach and social workers, O.T.s and other key personnel.  Any or all of these individuals can currently form part of the care plan for people recovering from severe mental health conditions.  In addition, there is access to third-party groups providing bridge building or similar services.  The return to mainstream life based on individual choices forms a strong part of the clinical and social models working together.

So what will be the scenario when mental health moves into the sphere of general practice, along with a host of other clinical services? 

In the UK, GP consortia are being set up with the intention of taking over from the primary care teams entirely by the year 2013. The primary care teams that currently incorporate a spectrum of care services for mental health will no longer exist.  It is uncertain whether GP consortia and GP surgeries will be equipped to respond to providing the clinical and social models which currently operate for people with 'severe and enduring' diagnoses.  What this means is that there could be no access to the key services that are well-positioned to provide access for the individual to his or her independence, recovery and self-development. 

The providers who currently enable access to mainstream life for people with mental health conditions will need to introduce themselves to the GP consortia as a matter of urgency.  In order to become better placed to continue the work of mainstream recovery it will be important to do this now.  Commercial and private providers are already muscling in on the GP consortia and it is unlikely that these groups will have any expertise at all in providing hope and aspiration for marginalised people.

Conspiracy of Hope

Pat Deegan's 'Conspiracy of Hope' .

What does Pat Deegan mean by a 'career in mental health'?

When Dr. Pat Deegan coined  the phrase 'a career in mental health' she was referring to endemic features of the mental health system prevailing at the time when she was first clincially diagnosed. A 'career in mental health' was the path that her specialists advised would become her future.  It would mean a life on benefits, no chance of employment and massively limited access to opportunities.  It would mean an end to her aspirations, and end to her hopes. Effectively, the end of a career.

For people who have been through secondary mental health experiences in the UK, a 'career in mental health' can still be the norm.  Huge inroads have been made nonetheless.  The recovery programmes that have been set up by many clinical teams all around the country.  The user-led services that are widely encouraged and supported.  The involvement in recruiting people who have experienced mental health conditions  for employment within services.  The movement from supported accommodation to independent living.  The emphasis on mainstream by third-sector organisations working alongside the NHS and statutory services.  The 'paths to personalisation' programme and the independence-based use of direct payments and personal budgets. 

These initiatives and more continue to help enable people with severe and enduring diagnoses to find personal autonomy and make a break from the pitifully bleak reality of Deegan's appositely-described 'career in mental health'. 

But what of the future?

In the UK we are witnessing the root-and-branch dismantling of mental health services as they currently stand.  There will be no more primary care teams and more and more people are being discharged from CMHTs (Community Mental Health Teams).  Within two years consortia of GPs and general practice surgeries will become the budget-holders both for primary and secondary mental health care. 

At this stage there is no way of telling whether these changes will be for the better or for the worse.  The only implacable fact is change itself, massive and across the board.

The fallout from the first tremors of change is already with us.  The much-vaunted personalisation programme was due to be rolled out universally throughout the UK within 18 months. Now it is unlikely to happen at all.  Personal budgets could well be forgotten in the midst of the general upheaval of services.  Certainly, direct payments for mental health have become a thing of the past, at least in the south-west London borough where I work as a bridge builder. This is despite service users having a legal right to direct payments where these can be shown to be a strong factor in their recoveries. 

The experience of personalisation in other parts of the UK may well be different and could paint a much more hopeful picture.  Unfortunately, in the tsunami of change it won't last.

Obliquity in Mental Health

Formulated by economic theorist and author John Kay, obliquity is the notion that complex goals are often best achieved indirectly.  As Kay puts it 'happiness is the product of fulfilment in work and private life, not the repetition of pleasurable actions, so happiness is not achieved by pursuing it'.

Kay is hailed widely as a perceptive business and organisational guru, but his ideas have a great deal of relevance in the mental health field.

Kay is very strong on the question of goals and defining business and personal objectives.  However his take is interesting as he does not have a straightforward linear viewpoint.

'We find out about the real nature of our goals in the process of accomplishing them, and our understanding of the complex structures of personal relationships or business organisations is necessarily incomplete', Kay writes.

John Kay underlines the importance of goals and goal-setting, which is commonplace in most business and personal development thinking.  But he emphasises that even when we set clear goals, we only 'find out about the real nature of our goals in the process of accomplishing them'.

Nothing could be more  true when this perception is applied to  mental health, recovery and mainstream.

As a social  inclusion bridge builder, I am employed to help enable clients set clear goals and prioritise a personal route into and through the mainstream environment.  But even when a client has prioritised one specific pathway, it can sometimes be the case that this will not be the area of mainstream that he or she will end up pursuing.

I have clients who have prioritised music or the arts but who soon find a place elsewhere - in sports, volunteering or employment, for example.

It used to be somewhat discouraging to find that clients were not engaging in their originally prioritised mainstream domains.  Now I check with other members of the bridge building team and find that many of my original referrals are now active in other areas.

Obliquity in action!

As John Kay puts it: 'the paradox of obliquity is all around us'.

Social Inclusion - so good for business

The business case for mental health awareness is evidenced by the increasing numbers of employers who are commissioning mental health awareness trainings for their workforce. Employers want trainings which enable their staff to understand more about common mental health conditions. Understanding mental health means that staff can work better with clients and customers. It also allows staff to feel less isolated about personal issues around health and well-being.

Mental health awareness provides the opportunity for employers and employees to find out more about the law as it relates to employment and mental health.

Enlightened employers will seek to develop a workforce team which is happy rather than unhappy, fulfilled rather than excluded. Courses such as MHFA (Mental Health First Aid) show that attendees often feel that one of the benefits of the training in that it allows for a safe space. A safe space where individuals can share feelings about their personal well-being in addition to learning about the broader aspects of mental health conditions and the appropriate interventions.

In addition to mental health, it makes solid sense for businesses to incorporate awareness of social inclusion and mainstream. Returning to or accessing mainstream living is now a key part of the care pathway for those diagnosed with 'severe and enduring' mental health diagnoses. It is equally important for people who may be experiencing conditions such as anxiety, phobia or stress at work.

Both groups - those in primary and secondary care - are being signposted to mainstream life rather than to special settings as a central plank of the recovery process. The implications for any service provider - and that includes businesses - are crucial. Businesses and services are at the receiving end of mainstream.

Clients in recovery are choosing to access their personal goals through a diverse range of outlets. These could range from faith venues to volunteer bureaus, from retail outlets to sports centres, from recording studios to adult education colleges, from libraries to personal counselors, from training venues to department stores.

For businesses, it's not just one in four of their staff who may be experiencing mental health challenges, it's also one in four of their clients, customers and service consumers. Mental health challenges will also have an impact on one in three families. Disclosed or undisclosed, it's clear that mental health and well-being lie at the heart of our transactions and interactions.