Open Mind issue 169 November - December 2011

Reconnecting lives Spirituality and mental health

WHAT'S NEW

FEATURES

• Care in crisis

• A pilgrimage in spirituality

• Peer support

• In search of the psyche

• Tribunal hearing in public

• Promoting spirituality

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Issue 169 November & December 2011

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BE OUR GUEST

Healing the spirit Psychotherapist Rameri Moukam talks to Open Mind about African centred therapy, restoring cultural identity and the role of spirituality in mental health care.

Pattigift Therapy CIC in Birmingham works from an African centred frame of reference to help people enhance self-knowledge and healing. What does African centredness mean and how do you apply this to mental health care?

African centredness is premised on a world view that, in the words of the Rastas, means ‘everything is everything’, that everything is interconnected and interrelated. This world view provides a cultural structure that is spirit based, holistic and circular unlike the Eurocentric world view that is material, linear, dichotomous and hierarchical. How does this pertain to mental health care? Just think on this for a minute. If you are black, and you are functioning within a cultural world view that is dichotomous and hierarchical, where does that put you in relation to whiteness? If you are a person who has assimilated a culture which dictates that consumerism is not only necessary but is the basis of self-esteem, where does that leave you if you are on a low income or unemployed? By providing individuals and the community with an alternative way of viewing the world and their place within it, we create an opportunity for self-definition, self-healing and self-determination. We cannot change the culture of ‘isms’ that we live in, but we can change our responses to it and the impact it has on us.

The work of spirituality can facilitate the brain to function in a way that is more harmonious with the body.

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We have accepted, physically, that we are what we eat. We now need to understand that, psychologically, we are what we think, and for most of our communities the way we think about ourselves needs to change.

In what significant way does African centred therapy differ from bio-medical models? And is there a place for bio-medical explanations of mental distress in this framework?

African centred therapy does have components of the biological model.

Medical model, not so much. We know that the spirit is manifest in the physical. I am not so sure about word making flesh, but quite sure of word making behaviour: how well our brain works bio-chemically affects how we respond to stimuli. The work of spirituality can facilitate the brain to function in a way that is more harmonious with the body. For example, we can learn to respond to a stressful situation in a calm and reflective way rather than with a ‘fight or flight’ response with all its hormonal and vascular consequences.

African centred psychology is based on spirit and spirituality. There is not really a place for bio-medical explanations of mental distress within this framework, but there is an acknowledgement of organic mental illness.

But in relation to mental distress, we see medication as a very short term solution that may reduce symptoms but does not supply real problem resolution.

What are some of the key issues affecting the mental health of people from black and minority ethnic communities?

First is racism. This culture requires a ‘cultural other’ onto which to project all of its negativity – remember our discussion about the dichotomous and the hierarchical? The other is different, we are better. Everywhere,

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all the time. Now, more interestingly, is internalised racism. We, as black people, have taken this position as true; we function as if we are inferior although we espouse equality. We run from and despise anything African or ‘ethnic’. Only that which is European is worthy, and in doing that we despise and destroy ourselves.

The second issue is the loss of cultural identity. Many of us, particularly African Caribbean people, don’t have even our own language. Even those of us who do, we no longer have our customs, knowledge base, symbols, values and ideas that provide a general design for living and ways of interpreting our reality. If your spirit-essence says one thing and your environment and experience say something else, the result is not going to be pretty – well it will be pretty confusing. With our innate need for balance, harmony and reciprocity, we will spiritually – unconsciously – do what is necessary to create stasis, this is our nature. We will become mentally distressed or ill.

Do you think the new mental health strategy and existing services are equipped to address these issues?

No. It would require a complete shift in mind-set. Personally, I am moving more and more towards the public health agenda. This for me is an environmental issue, just like diabetes or high blood pressure, or passive smoking. We cannot stop institutional or global racism; we can learn what preventative steps we can take to lessen our chances of being affected by it. We have accepted, physically, that we are what we eat. We now need to understand that, psychologically, we

are what we think, and for most of our communities the way we think about ourselves needs to change.

So how do you help people overcome these issues?

By working with the potential of the person who comes to have therapy with us, not just the set of symptoms that the person presents. We put the malaise into the psychosocial context of our current environment and normalise it. The fact that more of our community is not suffering from mental distress is the miracle of our resilience, not a reflection of the society in which we live. We remind people of their spirit that helps to redress the effects of racism and reclaim their cultural heritage.

How did you get involved in this work?

I became a psychiatric nurse by default, became a shop steward, got involved with and chaired the first voluntary sector African Caribbean mental health organisation, trained as a psychosocial nurse and then a psychotherapist, started my initiation into priesthood and found the African/black psychology movement in America. All of which lead me to facilitate the African centred model in the UK. What keeps you motivated?

Enough to say that Patti Gift is my grandmother’s name. The service that we have developed is part of my life’s work. Within African culture, there is a ritual called libation. This honours our ancestors and respects the work that they did for the community. Our purpose is to do good work so that our name is remembered. I give to my self by giving to others.

Find out more: www.pattigifttherapy.org

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on the agenda

Care in crisis: humanising services Mind’s inquiry into acute and crisis care finds pockets of positive practice but a significant need for system-wide changes.

Alison Cobb

C

risis and acute services are a crucial part of mental health care, providing for people when they are most vulnerable. Crisis is different for different people: people may be highly agitated, in despair, experiencing suicidal impulses or the need to self-harm, immobilised by depression, or frightened within the changed reality of psychosis. There is an urgent need for help. The response determines how people progress, recover, disengage or engage in future. And it is this stage in service delivery where the language of rights and care often collapses.

Crisis care inquiry Major problems continue in acute care, with people describing difficulties in getting help when they need it and wards that are not safe and therapeutic. The fourth report from the Mental Health Minimum Dataset shows that 39 per cent of people who spent time as an inpatient in 2009/10 were detained under the Mental Health Act – a rise of 7.6 per cent from the previous year. Despite the government’s five year plan to deliver race equality, the Care Quality Commission’s Count Me In census results over those five years show that detention rates have almost

consistently been higher than average for Black, White/ Black Caribbean Mixed and Other White groups.

Mind commissioned an independent panel to investigate the state of acute mental health services in England and Wales, create a vision for the treatment, care and support of adults with acute mental health needs, and make recommendations for how to bring it about.

What we heard Over the last year, the Panel examined evidence about care in inpatient wards, emergency departments, crisis resolution and home treatment teams and other community services. The 350 responses to the call for evidence, five hearings in England and Wales, and seven visits included the experience of service users, family members, staff and representatives of professional, provider and community organisations.

The Panel heard about good examples of care right across the acute sector. There were courteous and helpful staff making positive efforts to improve things, and well-designed environments. There were voluntary sector projects providing a different kind of response from the NHS, more

The Care in Crisis Panel The independent inquiry panel had a wide range of knowledge and experience, including that of using mental health services. The members were Paul Grey (chair), Helen Bennett, Martyn Cooper, Jayasree Kalathil, Rachel Perkins and Sashi Sashidharan. Paul Grey said: “There have been times during the inquiry process when I’ve heard someone’s personal experience of using crisis services and felt myself welling up with emotion. And I ask myself, is this really caring? Is this really the healing of the soul? But within hours we would hear of psychiatrists who took time to listen and empathise with an individual, which made so much difference to their experience. The journey so far has led the inquiry panel to believe that we must push for an institutional change in acute and crisis care in England and Wales. A good place to start is by putting the people who use these services at the heart of them — not buildings, systems, policies or models, but people. We have found so far that when this happens there are more successful outcomes for everyone involved.”

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Care in crisis’

What people want: excerpts from the evidence “…emotional space to talk to someone outside of my everyday life…. someone who can help me keep things in perspective, help me to connect with reality and not get lost and isolated in my own thoughts. This person needs to help me connect to the coping strategies I have to manage my distress so I don’t resort to unhealthy ways of coping like self harm and overdosing…” Service user “To know there was help readily available without having to jump through hoops.

People in crisis do not have the capacity to make appointments, phone calls, take long journeys or communicate what they need.”

Friend/relative directly accessible, though few and far between. There is no doubt that good acute and crisis care is achievable.

However, many people told us about poor to traumatising mental health experience. We should not be leaving people with urgent mental health needs isolated, frightened and unsupported in impersonal hospital settings; we should avoid traumatising those who use our services to such an extent that many of them would do anything not to return. Our services should not be engendering a sense of abandonment when people try to access them, putting them ‘on hold’ or have their crisis calls unanswered, or being told they are not ill enough to qualify for help, or waiting hours in A&E minded by security guards. Our services should not be discriminatory, treating some groups more neglectfully or coercively than others as it still

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appears to be the case for some black and minority ethnic (BME) communities.

There are four key areas we believe should be developed to turn this around.

Humanity What people want is to be treated in a warm, caring, respectful way – with humanity. Many of the experiences the Panel heard suggested that mental health services had lost touch with basic humanity when dealing with people in crisis, including unclean environments, lack of engagement and respect, and reliance on force.

Acute care should be built on human values and embody a culture of service and hospitality.

This will involve organisational commitment, a re-thinking of ‘professional distance’ from service users. There should be continuing measurement of satisfaction of

“The Harm Minimisation Policy for working with selfinjury should be mandatory in all MH services. Proper training for nurses and staff so people are no longer ignorant or afraid of self-injury and therefore won’t punish patients.”

Service user/advocate “A safe environment that is of a high standard of comfort, privacy and access to personal space – be it in own home, family home, residential facility. Guidance and engagement in determining the level and sort of help/ treatment provided. Support for friends, carers, family as appropriate. Regard for any previously completed plans, preferences, advance directives” Manager

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on the agenda

those receiving the service, staff support and development, and fresh perspectives from outside.

Training in the prevention, deescalation and management of disturbed behaviour must also be based in human values. The use of face-down restraint should be ended and we would like to see acute services work towards eliminating seclusion and restraint altogether.

Commissioning for people' s needs While there are common needs for care, safety, respect and someone to talk to, everyone’s crisis is different. A particular configuration of acute and crisis services may not be appropriate in all communities and diverse settings. Different service models may be needed in rural and urban areas, and for meeting the needs of BME communities. This means ensuring access to clinical mediation and advocacy and involvement of specialist community organisations in mainstream care provisions.

Commissioners should encourage flexibility and creativity in

providing personalised and community-specific solutions. They must demand accountability from providers that they are providing quality care that demonstrates humanity to all who need it.

Choice and control The first principle of choice and control in mental health crisis care is the right to define your own crisis.

Access to help was one of the biggest problems people told us about, both for those in crisis and those who could anticipate the need for more intensive help to prevent or cope with a crisis. Often, people were told they were not ill enough or did not meet criteria for particular services.

More direct access options are needed, where people can self-refer.

There should be an explicit acknowledgement that individuals know what they need. Crisis plans that are jointly developed in an independently facilitated process have been shown to reduce the use of compulsion, and give people more say over what happens when they may not be able to directly exercise choice.

Message from Paul Farmer Paul Grey and his colleagues have really delivered on expectations. Working with staff, our experts have given their time, energy and knowledge to create a strong vision for acute and crisis care.

We are heartened by the good practice they heard about, but we cannot ignore the many experiences that were far from perfect and in some cases appalling. This may make uncomfortable reading but we owe it to the people who took time to describe their experiences to us.

Being treated as a human being, respected, cared for, helped to recover or to better manage a problem, in a nurturing environment. These are basics that everyone can understand and it’s what the public demand and expect from their health service. It’s also what many healthcare professionals went into their professions wanting to do.

The change we want to see is not to be under-estimated.

It’s really big. We should take heart that it is happening already in some areas. But we can only achieve this shift by all working together across the NHS system. If we can do that, we will make this happen.

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Care in crisis’

Our vision for acute and crisis care One that is built on humanity, one with a stronger voice for the person in crisis, more care options, timely help and less compulsion. Staff are supported and different skills and abilities are used to best effect. The idea of a medical ward is replaced by a retreat; and acute and crisis services are well known as being people and places that provide healing and recovery.

Summary of recommendations For commissioners and health boards: • Review how far acute services are meeting local people’s requirements, and consult with black and minority ethnic communities in this process.

• Set clear standards for values-based services in the procurement or planning process and hold providers to account using measures that include service user/carer satisfaction.

• Expand the range of options to meet different needs, for example crisis houses, host families and survivor-led services, and include self-referral options.

For provider organisations • Consider ‘inpatients’ as ‘guests’ as well as recipients of care.

Review and get feedback on what standards of hospitality are being offered.

• Commit to working without violence and reappraise control and restraint methods, in particular ending face-down holds.

For teams • Carry out jointly negotiated crisis planning with people who may need to access acute care again in future.

• Remember how much people using services value time with staff and that empathy, kindness and respect go a long way.

For professional education providers • Market mental health professions and recruit on candidates’ values and qualities as well as skills.

• Re-evaluate how professional boundaries are taught so that staff can be confident to be themselves.

Reducing the medical emphasis People told us about the value of a range of professional and non-professional support and help.

While some emphasised ‘trained professionals’, a lot of people would prefer more peer support.

One of the most valued services we heard about was survivor-led; another recruited staff for their people and listening skills, not specific qualifications. In the NHS, we heard of a nurse-led team being more flexible than an equivalent psychiatrist-led team. The needs people described – care, safety, someone to listen, something to do – did not demand a medically dominant response. Psychiatrists are likely to be more effective, and their contribution more valued by service users, if they contribute as part of a team or are available to teams for consultancy rather than being ‘in charge’ or wholly ‘responsible’ for care.

Getting back to basics It is essential that this sector of care and the people who provide it are recognised as important and protected. However, in the current economic climate, it is equally important to look at how money is being spent.

The launch of the report of this inquiry kick-starts Mind’s campaign on acute and crisis care. We hope that our vision will chime with people using and working in acute care and that through collective effort we can build on existing good practice and good will to achieve real and lasting improvements to acute care provision.

Find out more • The full report and campaign details: www.mind.org.uk/CareinCrisis

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