Rachel Perkins Guardian interview August 25th 2010

The phrase "going against the grain" could have been invented for Rachel Perkins. Bring up any contemporary issue surrounding mental health and, chances are, the Mind Champion of the Year will come back with a question about why a particular approach is being taken and then advocate for an alternative.

State benefits, a hot topic, is a case in point. As someone who describes herself as "a child of old Labour", Perkins appears slightly uncomfortable that her views on benefits are in some ways in line with those of the Conservative and Liberal Democrat coalition government. She says she is "torn" by some Conservative plans, such as caps on housing benefit, yet is in agreement with the proposal for "tapering" benefit payments so that people are incentivised to work. "So that every hour that someone works counts," she says.

Equal citizens

She goes on to argue that the focus by some campaigners on defending entitlement to benefits can reinforce the perception that people with mental health difficulties need to be cared for, rather than being thought of as equal citizens. "Instead of talking about the right to work, we are now talking about the right to benefits. I don't think that's terribly healthy," she says.

"Every human being gains their self-worth from being able to contribute to their communities – and let's face it, the most socially sanctioned way to do that is with work."

Perkins, a clinical psychologist, is probably best known for her impressive efforts to get people with mental health problems back into work, and has spearheaded employment programmes at South West London and St George's mental health trust.

Civil rights is at the core of what Perkins advocates, and she raises the topic frequently. Discussions around mental illness should resemble those around physical disability, she says, where the emphasis has been successfully rooted not on impairment but in a "rights-based agenda". In part, her inspiration heralds from a strand of mental health advocacy in the US that promotes a "peer support" approach to recovery and firmly places mental health in the realm of a broader rights agenda.

The difficulty for mental health campaigners in Britain, she suggests, is that they can end up ghettoised when they should be tapping into wide-ranging issues around exclusion. Equally, too many of the messages put out about mental illness are couched in negative terms, she claims. "The mental health movement has spent so long looking inwards at the sort of services people get, not better lives. One of the things I really hated about the mental health world was its aura of doom and gloom. It was always, 'You can't do anything because of stigma and prejudice.' [The] image of possibility often gets lost in the conversation about stigma. I'm not some romantic, but [change] is possible."

In particular, Perkins gives short shrift to anti-stigma campaigns, which have attracted substantial funding in recent years. "I don't have any evidence that they [work]. I prefer not to use the term stigma, because it attaches to the person. We don't talk about the stigma of race. We talk about racism. The problem with anti-stigma campaigns is that they identify the class of people by their impairment," she says. "I want to see some empirical data [that they help people to get] a home and a job. The bottom line [is] I want to change behaviour."

Discrimination

As her long career in the NHS nears its end, one of the themes that Perkins, 55, intends to persevere with is challenging the expectations of the state and employers when it comes to getting people into work and keeping them there. Mental health awareness training is not the answer to discrimination, she insists, adding that it is wrongheaded to demand that employers do the "heavy lifting" for people with mental health problems in the workplace when the state should do more.

When asked in 2009 by the last government to head a review into how to support more people with mental health problems into work, for example, Perkins proposed that employers be given financial compensation by the state to cover some of the cost of long periods of health-related absence.

The ability to work was vital to how Perkins dealt with her own mental health difficulties, which manifested in the early 1990s. But her ambition goes beyond getting people jobs. She wants a transformation in how mental health is perceived. "We've got to look at civil rights in the context of mental health and citizenship, rather than, 'You are a poor unfortunate.' That kind of thing is a hiding to more discrimination."

Spitting people out

Perkins's career path offers some insight into how her views have evolved. She considered going into academia after finishing her PhD but quickly came to the conclusion that research was dull. She applied to train as a clinical psychologist only to find herself rejected as someone who would "wilt" outside the confines of a university. Undeterred, she applied for and got a job as assistant psychologist at Broadmoor, the high security psychiatric institution.

The experience reaffirmed what she instinctively felt: "I've always been concerned about the way our society is very good at spitting people out at the bottom. That's always bothered me."

Clinical training followed, as well as several other jobs, including stints in "the old state bins", the large Victorian asylums that once warehoused patients. Perkins attributes her belief that work is the best route to a better life to those early experiences. She describes one institution she helped close in 1990: "There were 40 beds to a dormitory. There were four baths in every bathroom. It's not a long time ago. They weren't safe places. Far from it. The average stay in that place was 30 years."

Winning the Mind Champion of the Year award last month is particularly special, says Perkins, because it was voted for by the public. Perkins beat household names such as Bill Oddie and Ruby Wax to take the gong. "I think [winning the Mind award] was much nicer than the OBE [awarded in June]," she says. "Being voted for was much better."

Perkins has no intention of easing into retirement and will be taking up consulting roles. "We've got to totally rethink mental health services," she says. "We need to be building up communities to accommodate mental distress and put professionals back in their boxes. I think what we've done is over-professionalise mental health."

Elaborating, Perkins explains that the irony of improvements in mental health service provision over the past 30 or so years – such as closing large asylums, introducing community-based services, and better access to a range of therapies – is that mental illness has been pathologised in a way that unwittingly promotes social exclusion of "a whole class" of people.

"The more we've developed highly sophisticated mental health services, the more, when we experience distress, we think, 'I've got to go to the experts.' Then [our] nearest and dearest think, 'Oh my god, they are not safe in my untrained hands. I've got to leave it to the experts.'"

It's not that mental health professionals aren't important or that therapy, drugs and other kinds of treatment don't have their place, Perkins insists. It is that an over-reliance on them stalls progress. "I'm not opposed to medication [for mental illness]. It's one of the things I use," she says.

What concerns Perkins is that often when trying to improve services – the recent emphasis by politicians and practitioners on "talking therapies", for example – the bigger questions around civil rights, dignity and independence are lost. "I don't believe that psychological therapy solves all ills. The more we translate the entire human process into therapy the more we render ordinary human misery and disturbance to the experts," she says.

Perkins's continued outspoken views on what still needs to change in the mental health arena are likely to ruffle the feathers of her fellow professionals and, if the ideas she promotes are eventually adopted, they could radically alter the way services are delivered

Recovery news from NHS North West

Manchester Mental Health and Social Care Trust are committed to a recovery approach to mental health care. One element of this is to support service users who want to move into employment. They are currently piloting an Individual Placement and Support (IPS) service, funded by NHS North West.

The project consists of three Employment Specialists, based with Community Mental Health Teams, who help service users to find and remain in employment. The service offers help in preparing for work and engages with both employer and employee to provide ongoing support.

Joanne, one of the service users, is just one of the people to benefit from the pilot so far. After discussing her wish to get back into work with her Community Psychiatric Nurse (CPN) she was referred to the team's Employment Specialist who used the Mental Health Recovery star to talk through Joanne's situation and where she wanted to be in terms of finding a job. They then developed an action plan and the Employment Specialist helped Joanne to find jobs that were suited to her work history and aspirations. Joanne decided that working part time would be the best way to ease back into work life and through regular meetings, the Employment Specialist helped her to explore job vacancies. Eventually they identified one position that suited Joanne in terms of job description, location and number of hours.

The Employment Specialist arranged a meeting with the Disability Employment Adviser at the local Job Centre for support with in-work benefit calculations, and completing a permitted work form with a supporting letter from the Employment Specialist. 10 weeks after engaging with the IPS service, Joanne was successful at securing a Receptionist post for 12 hours a week and stays in touch with her Employment Specialist who provides in work support.

For more information please contact Zeph Curwen, Service Manager Occupational Activity & Employment, zeph.curwen@mhsc.nhs.uk or 0161 720 4809.

For more information on the IPS project contact Lucy Rowe in the Health and Work Programme, Workforce Directorate: lucy.rowe@northwest.nhs.uk or 0161 625 7350.

MHFA - crisis intervention

In addition to the umbrella intervention provided by ALGEE (Assess Risk, Listen non-judgementally, Give reassurance, Encourage referral to other agencies, Encourage self-help strategies), MHFA has strong and clear guidelines for crisis intervention. From MHFA:
Crisis First Aid for someone experiencing an acute psychotic episode

• Do not get involved physically
• Call the police and explain what is happening, unless the person has a mental health crisis card with clear steps describing how you can help.
• Try to create a calm, non-threatening atmosphere.
• Be reassuring, calm and concerned.
• Do not try to reason with someone who is experiencing acute psychosis.
• Express empathy for the person’s emotional distress.
• Comply with reasonable requests

MHFA Testimonials & Feedback

MHFA Training delivered by Middlesbrough and Stockton Mind on behalf of the NE Mind Partnership have trained over 1800 individuals with outstanding feedback and results.

Mental Health First Aiders were asked for there stories on how MHFA has helped them. These are just a small selection;

I use MHFA daily, for example I had a tenant suffering a psychotic episode which I felt confident to deal with

I have used MHFA when a young Mum came into the centre and told me she felt like ending it all

I use it on a daily basis with clients and colleagues and feel I have made a real difference

I have a work colleague who suffers from epilepsy and associated depression and anxiety. I used ALGEE and offered advice and guidance over the phone.

MHFA interventions

Mental Health First Aid (MHFA) promotes five basic interventions for a qualified mental health first aider who comes into contact with signs and symptoms of a mental health condition. The action plan for Mental Health has five basic steps under the mnemonic ALGEE.

1. Assess risk (to oneself and the client)
2. Listen non-judgementally
3. Give reassurance and information
4. Encourage the person to get appropriate help and support
5. Encourage self-help strategies

Mental health condition can present across a spectrum, from mild sub-clinical concerns through to severe anxiety, distress and even full-blown psychosis.

A mental health crisis can occur when a person may feel suicidal or having anxiety attacks or be in an acute stress reaction or a person may be out of touch with reality in a distressing psychotic state. MHFA helps participants to develop and practice general strategies in a safe environment, that can be used in a first aid situation.

For a more in-depth course on suicide intervention skills it is recommended to attend an ASIST (Applied Suicide Intervention Skills Training) course.