The Ten Essential Shared Capabilities
Learning pack for mental health practice
Module 6:
Developing socially inclusive practice
Module 6
The Ten Essential Shared Capabilities Module 6:
Developing socially inclusive practice
Module 6 explores the link between The Ten Essential Shared Capabilities and developing socially inclusive practice. After completing this module, you will be able to: . Challenge the processes that lead to inequality and exclusion; 2. Adopt assessments and interventions that are inclusion-focused and usercentred; 3. Understand the importance of working in partnership with mainstream community organisations.
Contents
1. INCLUSION What does inclusion look like?................................................................ ............................. 2. ASSESSMENT - Your focus and your approach to assessment . 3. EXCLUSION - The processes and power of exclusion................................................. 4. COMMUNITY - Working beyond the mental health service.................................... 5. FOCUS - Getting and keeping inclusion......................................................................... 6. EMPOWERMENT - Unfinished business.......................................................................... 7. Links to further learning....................................................................................................... 2 4 8 10 13 16 18
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The Ten Essential Shared Capabilities
1. INCLUSION What does inclusion look like?
Activity 6.1
Write down the things that enrich your own life; things that are so important to you personally that they give life a sense of meaning and value:
Now move on to create a list of your feelings and actions if:
One or more of these were missing (imagine losing your home or a close friend):
You had to face serious problems (such as major illness, a bereavement, redundancy) in the absence of these things:
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The social inclusion agenda requires mental health services to pay attention to many of these things that make life rewarding. They are not just items on a list of predisposing factors, social circumstances or topics restricted to mental health promotion specialists they are critical to recovery. ESC4 (Challenging Inequality) expects staff to be actively involved (notice the action words) in challenging inequality, addressing discrimination and creating, developing and sustaining valued social roles for service users. One catchphrase of the inclusion movement is separate cannot be equal (Sayce 2000). This challenges the historical practice of developing a parallel world of segregated services for mental health service users homes for the mentally ill, sheltered workshops, separate college classes and creative writing groups for survivors of the mental health system. Instead, mainstream community organisations should be redesigned for everyone, and that includes people with mental health needs. Mental health specialists should deliver their expert support to people and communities in ways that assist them to get and stay connected with the wider community. On those few occasions when separate services are judged necessary, they should be transformed into stepping-stones to inclusion, not departure points for exclusion (Dunn 1999).
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2. ASSESSMENT - Your focus and your approach to assessment
For this part of the module you will need to obtain a standard assessment form that is used in your service (perhaps as part of the Care Programme Approach). The government has provided clear guidance about assessment, but despite this, local documents often neglect the inclusion agenda.
Activity 6.2
Take a few moments to review a blank assessment form in use in your local service against the following checklist: Is there a clear space to record the persons own viewpoint, or is it hidden behind phrases like agreed action plan? (See ESC3 Practising Ethically and ESC7 Providing Service User Centred Care) Does the form identify everyone who cares about the person? Notice that this question is about caring about a freely given, emotional response to the person as a whole rather than caring for which is about meeting needs (See ESC4 Challenging Inequality) Does the form give space to explore what is working and what is not working about the persons home life, occupation, relationships and leisure? (See ESC6 Identifying Peoples Needs and Strengths) Would a completed form give you insights into the persons history, long-term sense of what gives life meaning, and their hopes for the future? (See ESC5 Promoting Recovery and ESC6 - Identifying Peoples Needs and Strengths)
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Good organisation can help to keep us on the right track, but sometimes the culture of a mental health service highlights other priorities. Pressure of work, responding to crises and defensive practice can all narrow the focus. Restoring a social inclusion focus (Bates 2002) may demand action in all the following areas:
Narrowed focus A social inclusion focus adds the following dimensions: The persons positive social roles, such as householder, employee, parent, friend. The persons ambitions and goals for the future Review this by examining your work with one service user Does the care plan include actions to support the person in these roles? Are therapeutic interventions designed to assist the person to identify and move towards their preferred lifestyle? What opportunities does the person have to enrich the life of other people? Do the people contacted by the care team represent helping or community organisations? (Thinking beyond this one service user now) How much staff time is ringfenced for spending with people from non-mental health agencies?
State of the persons mental health as a user of mental health services Responding to crisis and coping with today
The person as a recipient of help Community organisations that offer help
The person as a contributor to society Community organisations that offer positive status and roles outside the mental health service Building new alliances beyond the mental health service
Growing strong teams within the mental health service
What were your answers to the questions in the right-hand column above?
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Activity 6.3
Write down some ways that you could be more socially inclusive in the work you do: . 2. 3. 4.
Before we leave this section we need to think about two specific groups of people: Those who say they like segregated services where they are surrounded by other mental health service users and staff. They simply prefer a day centre to a job, a mental health class to a mainstream class, a hospital ward to home treatment. Those who are considered to need segregated services for their own or other peoples safety or to give them the time and space to recover (e.g. in a therapeutic community).
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Activity 6.4
How do people get into these groups? Consider the influence of: What would help people to get out of these groups? the person themself relatives and friends schools and community organisations health and social care services police and criminal justice agencies general public and the media
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3. EXCLUSION - The processes and power of exclusion
In order to combat social exclusion, we need a good understanding of how it works in society and affects individuals (SEU 2004; see also ESC 4 Challenging Inequality). The following three definitions describe distinct but inter-related elements. Inclusion as access. People using mental health services should have access to the decision-making places where their personal care is reviewed and planned; where services are designed, managed and audited; and where jobs and promotions are offered. Inclusion as standard of living. People using mental health services should have the same opportunities as other citizens to enjoy employment and income, healthcare, housing and community safety, civic and legal rights. Inclusion as relationships. People using mental health services should have the same opportunities to establish and maintain respectful connections and friendships with a diverse array of other citizens. (Bates 2002)
Consider the following case examples in turn and build up a detailed story of a typical journey into an excluded life that might be experienced by a person from the first onset of mental distress (Mind 1999).
Activity 6.5
Consider how the three aspects of inclusion listed above impact on the persons life and become mutually reinforcing. . Do factors such as age, gender or ethnicity affect the journey? (See ESC2 Respecting Diversity). 2. Do mental health services sometimes make exclusion worse? 3. What do these services do to help the return journey?
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Neeta became suicidal soon after the birth of her first child. Her potential journey into an excluded life:
Whilst at university, Jason worked at Burger King until 3am three nights a week. After a few weeks, the doctor was called to his flat, as he seemed to be hearing voices. His potential journey into an excluded life:
Whilst each persons journey into an excluded life is unique, the themes of access, standard of living and relationships often appear. An alternative way to think about this journey was given by the Social Exclusion Unit (2004) in the following diagram. See how it works with the stories about Neeta and Jason that you have just developed.
Withdrawal & rejection from society
Mental health problems
Unemployment
A Cycle Of Exclusion
Debt Homelessness
Loss of social networks
Worsening mental health
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4. COMMUNITY - Working beyond the mental health service
There are a variety of things that can be done to enable a person to get and keep their preferred lifestyle and these will be explored in section 5. First we need to help communities to be more respectful and welcoming towards people who have experienced mental distress. The viewing point from which we look at the wider community may be similar to our view of people who use services. The Strengths Model (See ESC6 Identifying Peoples Needs and Strengths) acknowledges that people who use services are a mixture joy and despair, achievement and disappointment, love and selfishness and then encourages us to pay extra attention to the persons positive talents and achievements. Indeed, some so-called problems need to be recognized as strengths, especially when working with people who have had a very lengthy contact with mental health services. Whilst it would be nave to think that people using mental health services have no problems, this deliberate focus on strengths is a way of restoring balance in a culture that is preoccupied with symptoms, deficits and difficulties.
Activity 6.6
Describe a person you know who uses mental health services anonymising their name and any other personal details: Find all the persons strengths and use only positive words dont say but or despite Pay particular attention to any difficult, antisocial or unattractive behaviour - seek out the strengths that are hidden inside these aspects of the person. Positive description of the person:
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This same viewing point can be adopted when facing the community. There is a harsh reality out there, of discrimination, hate crime, negative stereotypes and fear that is directed towards people using mental health services. However, this is only part of the story. Other citizens acknowledge their common humanity with people using services, promote equality of opportunity, and offer respectful support. The Strengths Model demands that we pay extra attention to the positive aptitudes and achievements of ordinary communities.
Activity 6.7
Consider your own experience and also find moments at work to collect positive stories from your colleagues and record an example of one of these here:
Whilst there are already many allies in ordinary communities, a great deal can be done to create further improvements.
Activity 6.8
Select a specific community organisation (such as a local college, JobCentre Plus office or a community centre) and work through the following questions. Has your mental health organisation identified a worker to lead liaison with this organisation, and do you have regular contact with them? (See ESC1 Working in Partnership) Have you located champions within the community organisation who will support your efforts to improve opportunities?
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Do you understand the community organisations targets, priorities, funding regimes and policies that may affect opportunities for people with mental health issues? Please say a little about this. Have you delivered information, training or mentoring to people in the community organisation? Please say a little about this. Have you seen increases in the numbers and satisfaction of people with mental health issues who are using the community organisation? Please say a little about this. Finally in this section, there are three options for delivering support. These are: Using mental health buildings where people meet other mental health service users and staff. This is the option that offers sanctuary or promotes exclusion (depending on your point of view). Examples include hospitals and day centres. Using buildings that are also used by other members of the community, but where the people with mental health issues remain together in a group. This is the option that offers geographical integration but minimal social integration. Examples include separate college classes and group rooms hired in community centres. Offering community bridge-building support to one person at a time to assist them to locate and join activities where they are shoulder to shoulder with the general public. Examples include Supported Employment and home treatment (ESC5 Promoting Recovery).
Since mainstream community agencies have watched mental health services deliver their support largely through the first or second options, some will repeat that pattern by offering to set up segregated services in their own facilities. Staff at the college or the sports centre may assume that the best way to meet the needs of people with mental health problems is to create a special group, rather than support people to join in alongside the general public. Building effective relationships with allies in these settings will help them to create inclusive opportunities.
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5. FOCUS - Getting and keeping inclusion
A comprehensive, inclusion-focused assessment will identify the preferred lifestyle of the person, as reflected in ESCs 5-9. It will also go some way towards identifying the persons inclusion history perhaps of unsuccessful attempts to engage in educational, work-related or leisure activities. Acknowledging the feelings that attach to these experiences and finding the courage to try again is a key part of the journey of recovery. Sometimes it is helpful to draw out the lessons that can be learnt from unsatisfactory experiences with community organisations.
Activity 6.9
Create a list of the negative things that you have heard or seen done that have formed barriers and made it more difficult for people to access community facilities:
When you have run out of ideas, start at the top of the list and suggest practical changes that the community organisation might make.
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It is sometimes slow and painstaking work to support an individual to reconnect with community roles and relationships (Repper & Perkins 2003). It requires creativity and persistence, along with careful listening to the persons preferences about the setting and the nature of the support they require. A wide range of approaches (Bates and Dowson 2005) can be used, and these can be grouped under the following headings: . Getting to know the person. Good questions will help staff to find out more about how the person thinks of their own recovery and what elements need to be in place to support that personal journey. 2. Getting to know the community. A good local knowledge of the informal community is vital if we are to support people and avoid slotting them into unsuitable activities. Community development workers, voluntary sector agencies and health promotion specialists can help with this task. 3. Building capacity in mental health services. Helping mental health services expand their knowledge of mainstream community organisations, the mental health benefits of inclusion and awareness of which support strategies are effective (See ESC8 Making a Difference). This also demands the replacement of the pessimistic predictions of the past (e.g. you will never work again) with recognition that people using mental health services can make a valuable contribution to their communities. 4. Building capacity in community organisations. We need to build alliances, deliver training, dismantle barriers, and highlight the benefits of reaching the mental health constituency (SEU 2004). 5. Support for the whole of life. An example of this would be making sure that medication is not altered the same day that the person returns to work. Family, friends, mental health services and colleagues in community settings all need to work together to help the person to get and keep their positive roles and connections (See ESC1 Working in Partnership). 6. Getting there and settling in. Assistance with choosing the right setting, getting ready to go, travelling and induction. 7. Sustaining participation. This involves supporting the person to move on from attendance into participation. It is important for any problems to be dealt with before they lead to the breakdown of the activity. Support needs to be transferred from the formal mental health system to the natural arrangements in the community setting (See ESC4 Challenging Inequality and ESC9 Promoting Safety and Positive Risk Taking).
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Activity 6.10
Think of a person that you know who currently spends most of their life in a specialist mental health setting but who might, with appropriate support, take up an inclusive activity. What arrangements might you put in place to address the seven areas (above)? . 2. 3. 4. 5. 6. 7.
If it is appropriate, arrange to meet with the person you have been thinking about. Build a plan, listening hard for suggestions that come from the person you are working with. Use the work that you have just done as a resource rather than as a way to take over or control things. If you cant meet with the person try to meet with someone who supports them a support worker, a key worker or a care co-ordinator.
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6. EMPOWERMENT - Unfinished business
Inclusion depends on a number of organisational factors. Consider the following and see if there is any action that needs to be taken with your team or line manager to create an environment where inclusive opportunities can flourish.
Activity 6.11
Empowering others is best done by empowered people. If you are feeling particularly powerless or pessimistic, then this needs addressing. Action needed: An inclusive lifestyle is unique to the person, resting on their own definition of recovery, but creative staff often support the journey. If staff are exhausted, then creativity will never come to birth; while a blame culture will kill it. Action needed: Inclusion demands that the policies and procedures of some services be reviewed and possibly redrafted. In particular, risk management policies or their local interpretations can have the effect of denying opportunities and reinforcing exclusion (See ESC9 Promoting Safety and Positive Risk Taking). Action needed: Finally, working for inclusive opportunities is usually important but rarely urgent. This means that, without ring-fenced time and resources, it will be squeezed out. What priority does the local mental health service really give to the inclusion agenda? Action needed:
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Now that you have completed the module here are Three Key Questions to assist you in further learning: . Can you say what inclusion means to each person you work with? 2. Is a detailed inclusion plan part of their care? 3. Where does inclusion fit into your own personal development plan?
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7. Links to further learning
Bates, P & Dowson S (2005) Social Inclusion Planner Ipswich: National Development Team Bates, P (ed) (2002) Working for Inclusion London: The Sainsbury Centre for Mental Health. Dunn, S (1999) Creating accepting communities: report of the Mind Inquiry into social exclusion London: Mind. Repper, J & Perkins, R (2003) Social Inclusion and Recovery: A model for mental health practice London: Balliere Tindall. Sayce, L (2000) From Psychiatric Patient to Citizen: overcoming discrimination and social exclusion Basingstoke: MacMillan. Social Exclusion Unit (2004) Mental Health and Social Exclusion London: Office of the Deputy Prime Minister
Websites
To find out more about how English mental health services are responding to the social inclusion agenda, see http://www.nimhe.org.uk/priorities/socialinclusion.asp To put the English situation in the context of an international viewpoint on mental health and recovery, see http://www.bu.edu/cpr/ To place mental health work in an international and historical context of the development of human services, see http://soeweb.syr.edu/thechp/
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