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.

Mainstream - the Cascade Effect

As a social inclusion bridge builder I work with clients with severe and enduring mental health diagnoses. They are referred or they self-refer with the desire to access mainstream life domains.

Clients aspire to a variety of mainstream choices. It might be volunteering or befriending, it may be arts activities, it might be employment or running your own business. Client aspirations may include sports, faith, education, training or a selection from any or all of these.  All drawn from the life domains identified as key by the inclusion think-tanks of the late 90s and early 2000s.  Access to mainstream as a key component of the care pathway.

Enabling individuals with a 'severe and enduring' background is not always a straightforward process although it certainly can be sometimes. A client can be introduced to a mainstream outlet and it can work for him or her almost immediately. Other clients may be unready for mainstream for a variety of reasons. They may suffer a relapse before accessing the mainstream environment. They may visualise mainstream as another form of day service or statutory support system, which it isn't.

Equally, clients can sometimes express a wish to access mainstream out of a misplaced fear that not accessing it might in some way affect their payments and benefits. It can be a long process before the value and rewards of mainstream are understood.

What is true is that clients who successfully access or re-access mainstream in turn become examples of mainstream's effectiveness. Signposting to mainstream as part of the mental health recovery pathway is undoubtedly effective, even if it does not work for everyone straight away.

Mainstream also helps to sustain recovery in the individual and even better, it can propagate more success and recovery out of its own resources. An example of this would be the musician who successfully links up with a mainstream recording studio. After months of regular rehearsal the musician is invited by the studio manager to contribute to a recording session. I witness this kind of beautiful outcome and its benefits for the client in my work as an arts bridge builder.

Another example - again from music bridge building - is the guitarist client who uses a studio regularly and invites a friend to join him during the session. The friend may well be another mental health service user who has never successfully engaged with mainstream despite the best efforts of the bridge building service. Where services have been unsuccessful a friendship and peer network can do the job far more effectively.

Mainstream reaches the places other services cannot reach and in the process it is able to create a cascade effect - a continuing path of development, recovery and individual growth.

A mainstream model for recovery

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 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 bridge builder.

Discussing Mainstream

Bridge building for mainstream is now incorporated into the care pathway for people recovering from mental health conditions.

Community mental health teams, occupational therapies, psychiatrists are all aware of the value of mainstream bridge building. Many community mental health teams actively promote mainstream as part of their in-house practice with clients. Service-user led initiatives are also widely encouraged.

Where mental health teams may not always the time and resources to promote mainstream fully, there are many outside organisations working alongside the teams. The benefits of referral to an outside non-clinical team can be considerable.

Mental health teams can often discuss mainstream with clients in a clinical or home setting. An outside organisation has more time and capacity to draw clients out into mainstream settings where a conversation can begin. This may well be and should be - a conversation about the client's hopes, dreams, goals and aspirations.

One of the bridge builder's roles is to help facilitate this conversation. Another role is to be clued-in with what mainstream has to offer. For example, a bridge builder specialising in arts and culture needs to know what outlets there are both locally and further afield. A client who wishes to develop skills in music production should be introduced to the mainstream venue or venues where this opportunity takes place.

History of Social Inclusion

Social Inclusion and mainstream arise out of a history and out of a history of ideas.

Government think-tanks in the late 1990s and early 2000s had a key role in developing current thinking and practice around social inclusion. The envisaging of 'social domains' relevant to people's lives arises from these seminal ideas. The role of mainstream bridge builder is also developed around the concept of mainstream as a pathway for mental health recovery.

Social Inclusion goes back even further. The single act of defiance by Rosa Parks in 1955 in Alabama Mississippi. A black woman refusing to give up her seat on the bus to a white person, thereby defying the segregration laws. A key moment that lies at the heart of the civil rights movement, not just for the United States but for equality and social inclusion everywhere.

Equal opportunities, diversity, social inclusion and fairness are now commonplaces, enshrined in the way we strive to live and work today.

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Social Inclusion Web

Two major assessment tools have been developed for social inclusion.  One is the social inclusion 'Web' and the other is the 'Star' or 'Recovery Star'. 

Originally created by the National Development Team (NDT) the web is a simple and effective assessment tool based on five key social domains.  The domains were identified as key in the research done in the late 90s and early 2000s around social inclusion.  Other domains were identified alongside these and on the social inclusion web these appear as: Employment, Education & Training, Arts & Culture, Faith & Cultural Communities, Volunteering & Befriending.  Family & Neighbourhood and Services also have sections on the web.

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.

MHFA England John Vanek: Social Inclusion

MHFA England John Vanek: Social Inclusion

The Business Case for Mental Health Awareness

The Business Case for Mental Health Awareness. The economic and social cost of mental health problems in the United Kingdom is well documented. In 2002/03 the economic and social cost of mental health problems in England was £77 billion. (SCMH, 2003). The economic and social cost of mental health problems is greater than that of crime and larger than the total amount spent on all NHS and social services in the UK (HM Treasury, 2005).

Dame Carol Black's 2008 report 'Working for a Healthier Tomorrow' was a major attempt to address these concerns. Legislative review such as the 2005 amendments to the Disability Discrimination Act (DDA) highlighted the need to address the massive economic and social attrition behind issues of mental ill-health. In 2005 the Confederation of British Industry was concerned enough to commission its own research. Stress, anxiety and depression accounted for a third of the 168 million working days lost in the UK for health and related reasons in 2004, translating to a cost of sickness absence of about £4.1 billion (Confederation of British Industry, 2005).

As a result of legislation, employees have more rights and employers more responsibilities relating to the incidence of mental health in the workplace. Employees who choose to disclose a mental health condition to their employers are strongly protected by legislation and have the right to 'reasonable adjustments' that they may request their employers to make. In practice, it is still true that people with mental health diagnoses may well feel little confidence in this legislation. Nonetheless, their rights are enshrined in law. Similarly, employers have a legal responsibility not to discriminate against employees who have disclosed a mental health condition and to make any reasonable adjustments that have been requested.

Employers getting down with mental health

Helping employers to understand issues around mental health is fast becoming a key component of approaches to productivity, staff happiness, improved services and profits.

It is employers, managers and directors who are taking the lead on many of the new initiatives around mental health.

Supported by business ‘dragon’ Duncan Bannatyne, Mind’s ‘Taking care of Business’ campaign highlights the initiatives being taken by employers around issues of mental health at work.

The Mind campaign underlines the message that the promotion of good mental health helps employers ‘increase productivity, improve staff performance and save thousands of pounds’.

Mind also hosts a series of follow-up programmes designed to actively encourage good mental health in the workplace.

Some of the companies who have signed up to support the Mind campaign include EDF energy, BT, Hewitt Consultancy, AXA and police and security services. James Kenrick at Hewitt Associates helped set up an Employee Assistance programme allowing staff access to counselling services where appropriate.

Hewitt also initiated a staff health audit which identified stress, anxiety and depression as ‘real issues within the organisation’. James Kenrick states that:

‘after the health audit we sourced a stress vocational rehabilitation service, which has a vocational focus and is staffed by psychologists. Employees who have been absent for 10 days or more are referred for an initial assessment, and recommended the most appropriate treatment plan. We have found that this service, along with early intervention, has greatly reduced the days lost through stress-related absence and stopped stress-related disability altogether’.

Proactive management of mental health in the workplace has allowed Hewitt Associates to save ‘nearly £400’ per employee. More importantly, as Kenrick states:

‘it's the intangible elements that are most rewarding. The feedback from staff who have been helped to recover from difficult circumstances has been exceptional’.

EDF Energy is a major electricity provider. A workplace audit showed that the company was losing around £1.4m in productivity each year as a result of mental ill health among its employees. As part of an Employee Support Programme the company offered psychological support (cognitive behavioural therapy) to employees and trained over 1,000 managers to recognise psychological ill health among staff and to minimise its effects. This resulted in an improvement in productivity which saved the organisation approximately £228,000 per year. Job satisfaction also rose from 36 to 68%
(Business in the Community, 2009).

Happiness and Profits

Helping employers to understand issues around mental health is fast becoming a key component of approaches to productivity, staff happiness, improved services and profits.

It is employers, managers and directors who are taking the lead on many of the new initiatives around mental health.

Supported by business ‘dragon’ Duncan Bannatyne, Mind’s ‘Taking care of Business’ campaign highlights the initiatives being taken by many employers around issues of mental health at work.

The Mind campaign underlines the message that the promotion of good mental health helps employers ‘increase productivity, improve staff performance and save thousands of pounds’.

Mind also hosts a series of follow-up programmes designed to actively encourage good mental health in the workplace.

Some of the companies who have signed up to support the Mind campaign include EDF energy, BT, Hewitt Consultancy, AXA and police and security services. James Kenrick at Hewitt Associates helped set up an Employee Assistance programme allowing staff access to counselling services where appropriate.

Hewitt also initiated a staff health audit which identified stress, anxiety and depression as ‘real issues within the organisation’. James Kenrick states that:

‘after the health audit we sourced a stress vocational rehabilitation service, which has a vocational focus and is staffed by psychologists. Employees who have been absent for 10 days or more are referred for an initial assessment, and recommended the most appropriate treatment plan. We have found that this service, along with early intervention, has greatly reduced the days lost through stress-related absence and stopped stress-related disability altogether’.

Proactive management of mental health in the workplace has allowed Hewitt Associates to save ‘nearly £400’ per employee. More importantly, as Kenrick states:

‘it's the intangible elements that are most rewarding. The feedback from staff who have been helped to recover from difficult circumstances has been exceptional’.

EDF Energy is a major electricity provider. A workplace audit showed that the company was losing around £1.4m in productivity each year as a result of mental ill health among its employees. As part of an Employee Support Programme the company offered psychological support (cognitive behavioural therapy) to employees and trained over 1,000 managers to recognise psychological ill health among staff and to minimise its effects. This resulted in an improvement in productivity which saved the organisation approximately £228,000 per year. Job satisfaction also rose from 36 to 68%
(Business in the Community, 2009).

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Planning for Good Mental Health & Social Inclusion - testimonials

Planning for Good Mental Health & Social Inclusion

Training testimonials from NHS and Primary Care attendees

'Such a huge subject - well covered in the time allotted'.

The course has enabled me to be 'more assertive in recognising and prioritising mental health issues'.  I shall 'develop a knowledge base of local services and encourage others to make appropriate referrals'.

'John is a very calm person. Used the background music to create a non-threatening, relaxed atmosphere'.

I shall 'explore in greater depths what services are available to individual clients'.

'I feel I am more aware of what to look for in myself and others'.

The course 'has made me more aware of the need to ensure people return to mainstream after illness'.

'Ideas and information given to think outside the box'.

The course reinforced 'the importance of mainstream social inclusion'.

I now have 'more awareness of organisations and can utilise the social inclusion 'web' tool in assessments.'

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Traditional cohorts in mental health

Service providers, staff, service users and carers are often perceived as the main groups comprising the traditional cohort of secondary mental health care provision.  All this changes when mainstream practice is incorporated into care pathways.  


The effect of mainstreaming is that it introduces new stakeholders into the equation. Stakeholders chosen by the client as part of his or her recovery.  Person-centred practice is designed to enable the person in recovery to access activities and outlets of their own choice in the mainstream environment.  These outlets can be anywhere and everywhere, depending on the client's personal goals, hopes and aspirations.


Mainstream effectively destroys the stigma attached to recovery as it is longer attached to special settings,  wherever this is the individual's preferred choice.