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The Mental Health Continuum and Counselling

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GAD7 - Generalized anxiety
OCD - Obsession/compulsions or both, repetitive behaviours, time-consuming e.g. take more than an hour per day, impact daily functioning. Assessment done over phone or in person and lasts an hour. As questions like do you wash and clean a lot.
Panic disorder - Attacks aren't due to physiological conditions or come from another anxiety condition, must be consistently worried about having another attack for longer than one month.

Ethical Concerns
Come with the treatment, potentially causing distress to the client when trying to help them to overcome their anxieties or finding the source.
Waiting lists and access.

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Managing Anxiety in the Counselling Room

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Managing Anxiety in the Counselling Room

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Build up a rapport to make the client feel at ease, be very clear about the contract so no uncertainty.
Explain uses of anxiety, normalize it.
CBT techniques.
Focus on giving clients coping techniques for managing it such as breathing techniques and progressive muscle relaxation.
Usually there are triggers for it which may or may not be obvious to the client. Focus on managing symptoms first, then getting to the root cause for successful therapy.
Clients minds are often racing so being mindful to make sure you give them time and space to organise thoughts and take information in.

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Generalized anxiety
OCD
Panic disorder
PTSD
Social anxiety

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- Feeling nervous, restless or tense
- Sense of impending danger, panic or doom.
- Increased heart rate
-  Rapid breathing (hyperventilation)
- Trembling, feeling weak or tired
- Trouble sleeping and concentrating
- Urge to avoid things that trigger anxiety
- Changes in appetite
- Feeling irritable

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LibGuides: CU Coventry Referencing in APA Style: Home

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What is a complex group?
I think a complex group could be defined as people who have more than one issue that could put them at risk, such as being a minority ethnic and a member of the LGBT+ community, or a refugee who does not speak English and also has a physical disability.
Are some more complex than others?
In my opinion, they could be due to how stigmatized or severe their situation is and also what legislation protects them or stands in their way. For example, a black, Muslim, single mother seeking asylum with her 6-month-old baby would probably have a harder time finding support than an older person with a history of violence and a sensory impairment living in a care home.

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refugees, asylum seekers and stateless person

people moving home (students)

people who do not speak English

women who are pregnant or have a child aged under 12 months

children living at a socio-economic disadvantage

children with parents who have mental health or substance misuse problems

looked-after children

adults with a history of violence of abuse

people with poor physical health

older people living in care homes

isolated older people

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Certain subgroups of people can be more at risk of mental health issues due to societal challenges. This includes people who identify as:

black and minority ethnic groups

people living with physical disabilities

people living with learning disabilities

people with alcohol and/or drug dependence

prison population, offenders and victims of crime

LGBT

carers

people with sensory impairment

homeless

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Environmental Factors for Mental Health 

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Environmental Factors for Mental Health 

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Deprivation and being at a relative disadvantage in terms of having fewer resources than others can affect mental health negatively. This includes:

poverty and financial security

housing and homelessness

education and lifelong learning

employment and working conditions

crime and justice

community wellbeing

social capital

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1. Introduction

The purpose of the mental health and wellbeing JSNA toolkit is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. This chapter helps consider factors related to the promotion of mental wellbeing and the prevention of mental health problems. It provides easy access to nationally available topic focused information, guidance and knowledge. The chapter text aims to be plain English and ready to be cut and pasted. The numerous links to external sites should all be current, relevant, and provide access to material that contributes to the JSNA process.

Understanding the local population is vital for good needs assessment and service planning. The characteristics of the local relevant population (for example, size, age and gender) should be known, including how this drives demand for mental health services now and in the future. Specific groups of people should be identified who are at risk of developing, or likely to have, mental health problems and who may benefit from targeted action for prevention and to ensure their needs are met.

To identify inequalities in prevalence of mental health problems, access to services and outcomes it can be helpful to look at population sub-groups. This segmentation looks at difference by gender, ethnicity and other 'protected characteristics' as defined by the Equality Act. Understanding how people with such characteristics experience different levels of mental health problems to the general population will add context to any variation identified. Segmentation can also consider differences by geography and variation in exposure to social 'place' effects covered in Mental health: environmental factors.

Alongside mental health across the life-course (documents 4 to 7), there are important causes and consequences of mental health problems worth considering for the local population in terms of health improvement and prevention. These include health behaviours such as smoking, physical activity and misuse of alcohol and drugs. The inter-relationship between mental and physical health is important. Poor physical health increases the risk of developing mental health problems, and vice versa. Mental health problems are common in people with longer-term conditions such as cardiovascular, respiratory and liver diseases, cancer and chronic pain.

People with mental health problems, particularly those who do not access treatment early and with more severe conditions, experience poorer physical health and reduced life expectancy. One measure of local population vulnerability is the level of self-harm across the life-course. While not mental health outcomes in themselves, suicide and self-harm are closely related to factors associated with mental health.

Questions that a JSNA might address, based on the JSNA data inventory:

what different populations should be considered when commissioning mental health services?

how is the population changing? What will it look like in 5 and 10 years?

what is the level of life satisfaction and happiness scores in the different local populations?

what is the level of understanding about how to develop positive mental health and wellbeing in this population?

how many people have complex or additional mental health needs?

what are the main social, and physical and mental health inequalities in the area?

what are the local rates of safeguarding and crime prevention?

how do health behaviours affect mental health and wellbeing in this population?

what are the physical health needs of people with mental illness?

what are the mental health needs of people with physical health conditions - are they being recognised and met?

are preventive measures being provided to those who need them most?

what are the rates of suicide and self-harm and are interventions in place?

2. Population demographics and vulnerable groups

Avoidable, systematic inequalities between groups are unfair. Action can be taken to reduce these. Some people experience several complex interrelated issues, and many will fall into more than one subgroup. Local areas should have their own knowledge of vulnerable or marginalized groups and perspectives on local equality issues.

2.1 Overview

The age and gender structure of the local population is a important driver of health need and demand for health services. Allocation of NHS resources for mental health (including dementia) is based on modelling mental health condition prevalence against known factors, such as acute mental health need being greatest among working age adults and dementia being more prevalent among older age groups. Some further weighting is included for ethnicity and socio-demographic factors.

black and minority ethnic groups (BAME) (see 'equity of access' chapter)

people living with physical disabilities

people living with learning disabilities

people with alcohol and/or drug dependence

prison population, offenders and victims of crime (see 'crime, safety and violence' in Mental health: environmental factors)

LGBT (lesbian, gay, bisexual and transgender) people

carers

people with sensory impairment

homeless people (see 'housing and homelessness' in 'Mental health: environmental factors')

refugees, asylum seekers and stateless person

High rates of people moving home within and between areas can disrupt social ties and community networks and is related to higher levels of stress and mental health problems. This can include people in life transitions such as students. People who have recently arrived from abroad to live in an area may face barriers to accessing mental health services.

People who do not speak English well might need specific help to enable them to access the mental health services. Refugees are more likely to have experienced trauma and have higher prevalence of mental health conditions such as post-traumatic stress disorder ( PTSD), depression and anxiety.

Other examples of high risk groups are highlighted in Mental health: environmental factors. In particular, higher rates of mental health problems are associated with poverty and socio-economic disadvantage. Across the life-course (documents 4 to 7), examples of groups identified as high priority are:

women who are pregnant or have a child aged under 12 months

children living at a socio-economic disadvantage

children with parents who have mental health or substance misuse problems

looked-after children

adults with a history of violence of abuse

people with poor physical health

older people living in care homes

isolated older people

2.2 Data sources

It is expected that demographic profiling of local populations has been undertaken elsewhere in the wider JSNA process. Important sources of demographic data include:

2.3 Local data

Local authorities will hold population and demographic data and may have additional local information on specific at-risk groups based on local data collection and surveys. There is likely to be a lack of data about some groups, due to it not being collated nationally.

2.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

3. Equity of access (with particular focus on ethnicity)

Social characteristics, such as gender, disability, age, race and ethnicity, sexual orientation and cultural attitudes influence access to support and services.

3.1 Overview

It is a legal requirement that access to mental health services should not be discriminatory on the basis of protected characteristics as defined by the Equality Act 2010. Protected characteristics are:

age

disability

gender reassignment

marriage/civil partnership

pregnancy

race

religion or belief

sex

sexual orientation

For instance, the needs of older people not being adequately considered when planning mental health services would potentially be considered discrimination.

It is also illegal to discriminate directly or indirectly against people with mental illness in public services and functions. Mental illness is defined as a disability characteristic if the 'mental impairment has a substantial and long-term adverse effect on a person's ability to carry out normal day to day activities.

Research and equalities policy has given significant attention to the disparities in access to, and experience of, mental health services according to ethnicity. People from black and minority ethnic ( BAME) groups living in the UK are more likely to:

be diagnosed with a mental health problem

seek help in a crisis situation and in A&E

be admitted to hospital with a mental health problem

experience a poor outcome from treatment

disengage from mainstream mental health services

People from black African and Caribbean backgrounds are disproportionately seen in the 'hard end' of services (for example, at the point of arrest) and are more likely to receive harsher or more coercive treatments. Due to the 'eurocentricity' of service design, people from some BAME communities struggle to access services in ways meaningful to them.

Detailed consideration of mental illness among BAME groups will require local action. This is likely to include local community engagement work and assessing the use of local support services by ethnic group through direct contact with providers (social care, CQC, advocacy services, specialist mental health, IAPT).

3.2 Data sources

Metrics in the profiling tool relating to ethnicity and equity of access include:

The Severe Mental Illness tool includes proportions by broad ethnic group.

The Adult Psychiatric Morbidity Survey 2014 provides national data on the prevalence of mental health conditions by broad ethnic group. This information can be drawn upon to help understand likely need of particular groups for support in relation to mental health problems and used in conjunction with demographic data to assess equity in uptake and outcome of available care services.

A range of equality indicators are recommended in Understanding local needs for wellbeing data. Data on quality or outcome of services for BAME users is not yet available but may be available locally direct from services.

3.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Public Health Matters: local action on health inequalities amongst ethnic minorities discusses understanding how ethnicity relates to inequality and health inequality and taking action to reduce ethnicity based inequality.

Race equality foundation and mental health providers forum: better practice in mental health for black and minority ethnic communities gives examples of best practice from organisations and projects promoting and addressing issues around mental health in BAME communities.

Ethnic inequalities in mental health: promoting lasting positive change is a summary of research and analysis in relation to people with a BAME background and mental health. Includes an overview of recent policy developments, headline statistics, and recommendations for action and investment.

Chief Medical Officer annual report: public mental health includes chapters on parity of esteem and on ethnic inequalities and social inclusion.

IAPT positive practice guides aim to increase access across the age spectrum and to meet the needs of diverse and underrepresented groups.

4. Smoking and health behaviours

Positive health behaviours, such as not smoking, eating healthy food, and engaging in physical activity, can encourage psychological wellbeing, improve physical health, prevent mental health problems, and support recovery among people who are unwell. In addition to supporting individuals to make healthy choices, interventions should focus on providing environments which support adopting healthy behaviours.

4.1 Overview

Smoking remains the single biggest cause of preventable death and illness in England. Smoking prevalence is higher among people with mental health problems than the general population (40.5% of people with a serious mental illness compared to 14.9% of the adult population). A third of all tobacco is smoked by people with a mental health condition. Smoking among those with a mental health condition has changed little over the past 20 years, in contrast to the marked decline in smoking prevalence in the general population.

Alongside smoking, there are a number of other links between health behaviours and mental health problems:

mental health problems in childhood predict unhealthy choices in adolescence

eating healthy food, particularly fruit and vegetables, can positively affect mental as well as physical health

physical activity can positively affect stress, self-esteem, anxiety, dementia and depression and is recommended in the treatment of depression

rates of obesity are higher among people with a mental health condition

Health behaviour, physical health and mental health are closely related. Each is a determinant and consequence of the other and all are underpinned by wider social factors. Mental health affects risk behaviours, including smoking, alcohol and drug misuse, higher-risk sexual behaviour, lack of exercise, unhealthy eating and obesity.

Risk behaviours cluster in particular groups. For example, low income and economic deprivation is associated with the 20 to 25% of people in the UK who are obese or smoke. This same population has the highest prevalence of anxiety and depression. Such clustering can lead to greater lifetime risk of mental health problems, as well as social, behavioural, financial, and general health problems.

Negative health behaviours are contributing causes of poorer physical health among those with mental health problems. It is likely that the high prevalence of smoking accounts for much of the reduction in life expectancy among people with serious mental illness.

People with mental health problems must have access to 'stop smoking' interventions where needed, as well as interventions for physical activity and obesity.

4.2 Data Sources

Metrics in the profiling tool that relate to smoking and health behaviours are listed below.

3 or more risky behaviours in 15 year olds (county and UA)

smoking prevalence in adults (county and UA, district and UA, CCG, region)

smoking prevalence in adults with depression and anxiety (county and UA, district and UA, region)

smoking prevalence in adults with long term mental health conditions (county and UA, district and UA, region)

excess weight in adults (county and UA, district and UA, region)

enough physical activity (county and UA, district and UA)

use of outdoor space for exercise/health (county and UA)

Other important data sources include:

Local data

Local areas may focus on access to, uptake and outcomes of health behaviour interventions for people with a mental illness and who smoke, and data on these local services will be an important element of the JSNA.

4.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

ASH's The stolen years sets out recommendations for how smoking rates for people with a mental health condition could be dramatically reduced.

Mental Health Foundation's Physical health and mental health includes a summary of the relationship between health behaviours and mental health.

The National Institute for Health and Care Excellence ( NICE) guidance Smoking: acute, maternity and mental health services aims to support smoking cessation, temporary abstinence from smoking and smoke free policies in all secondary care settings, including mental health services. Includes interactive pathway, baseline assessment, implementation advice and self-assessment tool.

PHE's Smoking cessation in secondary care: mental health settings provides guidance and self-assessment framework for NHS mental health trusts to develop local action to reduce smoking prevalence and the use of tobacco.

National Centre for Smoking Cessation and Training (NCSCT)'s Smoking cessation and smokefree advice including mental health provides support, guidance and advice on smoking cessation and smokefree policies, including a number of briefings specific to mental health.

PHE's Vaping in England: an evidence update provides the latest evidence on the prevalence of vaping in adults and young people and the use of e-cigarettes in stop-smoking services.

UK Faculty of Public Health's Better mental health for all - relationship with physical health and healthy lifestyles provides evidence and information about the links between physical health, mental health and healthy lifestyles.

5. Alcohol misuse and drugs

Harmful use of alcohol or drugs often contributes to or co-exists with mental health problems and leads to poorer outcomes. When people have co-existing conditions it is important that they access relevant treatment in line with NICE and other national guidance. They should not be excluded based on mental health or alcohol/drug use conditions that they may have ('no wrong door' principle). It is important that people experiencing mental health crisis are not turned away from services due to intoxication.

5.1 Overview

People with co-occurring mental health and alcohol/drug use conditions often have multiple needs, with poor physical health alongside social issues such as debt, unemployment or housing problems. They are also more likely to be admitted to hospital, to self-harm, or die by suicide.

Drinking more than the low risk guidelines can harm mental and physical health. It can also lead to social problems, such as unemployment, divorce, domestic abuse, and homelessness.

Regular consumption of alcohol has been shown to cause mental ill health including depression, anxiety, and a connection to higher levels of self-harm and suicide in people with alcohol problems. Regular heavy drinking can also lead to alcohol dependence. The relationship between mental health problems and alcohol is a vicious cycle. Mental health problems can cause people to drink more, particularly as people often drink alcohol as a form of 'self-medication'.

Drug misuse includes taking illegal drugs and the consumption of controlled prescription drugs, such as benzodiazepines, without a prescription. Estimates suggest that 2.7 million adults took illicit drug in the last year.

Research shows that mental health problems are experienced by the majority of drug (70%) and alcohol (86%) users in community substance misuse treatment. 41% of people entering community alcohol and drug treatment in 2017 to 2018 reported a co-occurring mental health treatment need. There are many factors associated with harmful alcohol and drug use. Drug misuse can cause social disadvantage, and social disadvantage may lead to drug use and dependence. Many are social factors, such as deprivation. Drug use and misuse tend to be clustered. For example, areas of relatively high social deprivation have a higher prevalence of illicit opiate and crack cocaine use and larger numbers of people in treatment. These also relate to mental health as discussed in Mental health: environmental factors.

Alcohol and drug misuse contributes to wider social harms such as:

absenteeism

unemployment

domestic violence

family breakdown

child maltreatment

public disorder

While there may be public perception of a relationship between violent crime and serious mental illness, between 2006 and 2016 11% of homicide convictions in the UK were known to be committed by mental health patients. Research suggests that substance misuse and socio-economic factors play a far more important role.

NICE recommends that staff in mental health settings should routinely carry out alcohol screening and ask service users about recent legal and illicit drug use, including type, method of administration, quantity and frequency. They should provide brief interventions, harm reduction information and signpost to specialist services. NICE guidance for people with coexisting severe mental illness and substance misuse outlines best practice which includes adapting existing secondary care mental health services to meet both a person's co-occurring severe mental illness and substance misuse needs and focusing on their wider health and social care needs. It is important to provide coordinated services that address their wider health and social care needs as well as other issues such as employment and housing. Empathy and respect are vital as people with co-occurring conditions are often stereotyped and stigmatized.

NHS England is leading work to redesign and reorganise core community mental health teams into a new community-based offer that will include access to psychological therapies, improved physical health care, employment support, personalised and trauma-informed care, medicines management and support for self-harm and coexisting substance use.

5.2 Data sources

Metrics in the profiling tool that relate to alcohol misuse and drugs

admission episodes for alcohol-related conditions (county and UA, district and UA)

3 or more risky behaviours in 15 year olds (county and UA)

estimated prevalence of opiate and/or crack cocaine use (county and UA)

admission to hospital for mental and behavioural disorders due to alcohol (county and UA, district and UA )

concurrent contact with mental health services and substance misuse services for drug misuse (county and UA)

concurrent contact with mental health services and substance misuse services for alcohol misuse (county and UA)

Other important data sources include:

5.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Alcohol Concern's An audit of the focus on alcohol-related harm in joint strategic needs assessments, joint health and wellbeing strategies and CCG commissioning plans focuses on the priority given to addressing alcohol-related harm in JSNAs, JHWS and Clinical Commissioning Group ( CCG) plans across England.

[ NICE's Coexisting severe mental illness and substance misuse: community health and social care services covers how to improve services for people aged 14 and above who have been diagnosed as having coexisting severe mental illness and substance misuse. The aim is to provide a range of coordinated services that address people's wider health and social care needs, as well as other issues such as employment and housing.

PHE's Better care for people with co-occurring mental health, and alcohol and drug use conditions gives guidance on commissioning and providing better care for people with co-occurring mental health, and alcohol and drug use conditions.

PHE's JSNA support packs for alcohol, drug and tobacco use will help local areas to develop JSNAs and local joint health and wellbeing strategies, which effectively address public health issues relating to tobacco, drug and alcohol use.

The Joint Commissioning Panel for Mental Health (JCPMH)'s Guidance for commissioners of drugs and alcohol services is based on evidence and developed jointly between professionals and people who use drug and alcohol services.

Turning Point's Dual diagnosis toolkit is a mental health and substance misuse guide for professionals and practitioners, written to support the development of services for people with co-existing mental health and substance use problems. At the heart of the handbook is a series of case studies showing how particular services have implemented good practice.

6. Comorbidity in mental and physical illness

Mental and physical health is totally linked. Mental health and physical health are both determinants and consequences of each other.

Overview

There is a strong argument that support for physical and mental health should be integrated. There are 4 related challenges:

high rates of mental health conditions among people with long-term physical health problems

poor management of 'medically unexplained symptoms' which lack an identifiable organic cause

reduced life expectancy among people with the most severe mental health conditions, largely attributable to poor physical health

limited support for the wider psychological aspects of physical health and illness

nearly 4 times the rate of deaths from diseases of the respiratory system

just over 4 times the rate of deaths from diseases of the digestive system

nearly 3 times the rate of deaths from diseases of the circulatory system

Much of the extra burden of poor physical health among those with mental health problems can be explained by health behaviors such as smoking and alcohol (see section 5). Other factors also play a part such as barriers to receiving adequate physical healthcare; less than a third of people with schizophrenia in hospital received the recommended assessment of cardiovascular risk in the previous 12 months.

NHS England is leading work to ensure that it meets the physical health needs of 280,000 more people living with severe mental illness by 2020 to 2021. This will be achieved by increasing early detection and expanding access to evidence based physical care assessment and intervention each year. Collaboration between public health, primary care and secondary care mental health services is crucial to realising this aim. This commitment was reaffirmed in the NHS Long Term Plan pledging £2.3 billion a year by 2023 to 2024 to invest with the ambition to increase the number of people receiving physical health checks.

The close relationship between mental health and physical health is strongly underpinned by the underlying social determinants of health, such as social deprivation. This is an important way in which inequalities are perpetuated and a broad public health strategy should consider the role of these social determinants for the whole population.

6.1 Data sources

Metrics in the profiling tool relating to comorbidity in mental and physical health

smoking in adults with anxiety or depression (county and UA, district and UA, region)

smoking in adults with long term mental health condition (county and UA, district and UA, region)

people with severe mental illness (SMI) who have received the complete physical health checks (CCG, STP)

excess under 75 mortality rate in adults with serious mental illness (county and UA)

Other important data sources include:

Public Health England's Return on investment (ROI) toolkit provides assessment of the ROI of interventions to protect the mental health of people with physical health problems

Understanding local needs for wellbeing data from the What Works Centre for Wellbeing provides recommended relevant indicators

Public Health England's analysis of the physical health inequalities of people with SMI uses a sample of primary care data to examine differences in prevalence of 10 physical health conditions between the population with SMI aged 15 to 74 years and the general population; it also looks at multi-morbidities between the 2 population groups and analyses health inequalities by age, gender and deprivation

6.2 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Improving the physical health of adults with severe mental illness: essential actions is a report from the Academy of Royal Medical Colleges and the Royal Colleges of General Practitioners, Nursing, Pathologists, Psychiatrists, Physicians, the Royal Pharmaceutical Society and Public Health England providing recommendations.

NHS Rightcare's Physical ill health and CVD prevention in people with severe mental illness toolkit was developed in collaboration with Public Health England. This toolkit provides expert practical advice and guidance to support system wide improvement to help improve physical health for people with severe mental illness and reduce health inequalities.

NHS toolkit Improving the physical health of people with a serious mental illness: a practical toolkit includes detailed case studies at pilot sites, short examples and supporting documents.

King's Fund's report Bringing together physical and mental health calls for integrated physical and mental healthcare. Provides examples of innovative service models and identifies areas where there is scope for improvement.

NHS England's report from the independent Mental Health Taskforce Five year forward view for mental health sets out recommendations for the NHS and its arms-length bodies to achieve the ambition of parity of esteem between physical and mental health.

NHS health check best practice guidance underlines the importance of physical health checks for people with severe mental illness.

PHE's Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health includes information on interventions to protect the mental health of people with physical health problems.

PHE's Wellbeing in mental health: applying all our health gives examples to help healthcare professionals make interventions to encouragephysical health and wellbeing in mental health.

Health Matters: reducing health inequalities in mental illness is a professional resource focusing on some of the actions local areas can take to reduce physical health inequalities experienced by people living with mental health illness.

World Suicide Prevention Day 2019 is a study by the National Cancer Registration and Analysis Service exploring data in the risk of suicide after cancer diagnosis in patients, and the risk between the types of cancers which are considered preventable.

7. Suicide and self harm

Every suicide should be seen as preventable. Gaining an understanding of vulnerability in local populations can aid development of an effective suicide prevention plan. People with a history of self-harm are a high-risk group for suicide.

7.1 Overview

The cross-government prevention strategy identified 7 important areas for action:

reduce the risk of suicide in high-risk groups

tailor approaches to improve mental health in specific groups

reduce access to the means of suicide

provide better information and support to those bereaved or affected by suicide

support the media in taking a sensitive approach to suicide and suicidal behaviour

support research, data collection and monitoring

reduce rates of self-harm as a major indicator of suicide risk

People with a history of self-harm are a high-risk group and a priority for prevention. Some groups have higher rates of self-harm, including young people, particularly looked after children and care leavers, and lesbian, gay and bisexual people. In a recent survey 22% of 15 year olds said that they had previously self-harmed, with almost 3 times as many girls reporting self-harm than boys.

People who self-harm are at increased risk of suicide; although for many people self-harm is a coping mechanism and not a suicide attempt. Risk of suicide is particularly increased in those repeating self-harm and in those who have used violent/dangerous methods of self-harm.

Other groups identified as high risk for suicide are:

young and middle-aged men

people in the care of mental health services, including inpatients

people in contact with the criminal justice system

specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers

Local areas should have multi-agency suicide prevention plans in place that contribute to a 10% reduction in suicide nationally by 2020 to 2021. By the beginning of 2019 every local area in England has a multi-agency suicide prevention plan in place or in development. The NHS Long-Term Plan will continue to make reducing suicides over the next decade as a priority by building on the progress that is already made.

7.2 Data Sources

Metrics relating to suicide and self-harm in the profiling tool

long-term unemployment (county and UA, district)

children in need due to family stress (county and UA)

children in need due to abuse or neglect (county and UA)

hospital admissions as a result of self-harm (all ages) (county and UA, district and UA, region)

hospital admissions as a result of self-harm (standardised admissions ratio) (ward)

emergency hospital admissions for intentional self-harm (county and UA, ward)

suicide: age standardised rate (males, all ages) (county and UA, CCG, STP)

suicide: age standardised rate (females, all ages) (county and UA, CCG, STP)

Other important data sources include:

Suicide Prevention Profile provides a range of metrics at local authority, unitary authority and CCG level to enable local areas to understand their need and benchmark against similar populations

7.3 Local data

Guidance on undertaking a needs assessment is in the local suicide prevention planning guidance, the 'Making sense of national and local data' section of the Local suicide prevention planning: a practice resource.

Local authorities may want to add to this information with local demographics such as migrant population figures and protected characteristics as defined in the Equality Act. Information collected for local suicide audits can help understand the demographics and circumstances of those in their area who have died by suicide. Some areas are setting up real time suspected suicide surveillance systems to reduce the time delay in obtaining information.

7.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Local Government Association: Suicide prevention a guide for local authorities is a guide for local councils on their role in suicide prevention, including a range of approaches and case studies to inform decision making.

Multicentre study of self-harm in England is a collaborative research programme between the University of Oxford, University of Manchester and Derbyshire Healthcare NHS Foundation Trust.

National confidential inquiry into suicide and homicide by people with mental illness provides the latest data and makes recommendations for improving clinical practice and service delivery to prevent suicide and reduce risk.

NICE's Preventing suicide in community and custodial settings is a quality statement around self-harm includes aspects of suicide prevention advice, particularly in the resource section (with particular reference to the use of risk assessments).

NICE's Self-harm pathway is a useful way to navigate through the stages of life course.

PHE's Suicide prevention - resources and guidance support local authorities and healthcare professionals to develop a suicide prevention strategy and implement action to reduce suicides and improve support for those bereaved or affected by suicide.

Samaritans' suicide statistics report provides details of England suicide rates (along with Wales, Scotland and the Republic of Ireland) and helps to understand and interpret suicide statistics.

8. References

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The purpose of the mental health and wellbeing JSNA toolkit is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. This chapter helps consider factors related to the promotion of mental wellbeing and the prevention of mental health problems. It provides easy access to nationally available topic focused information, guidance and knowledge.

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1. Introduction

The purpose of the mental health and wellbeing JSNA toolkit is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. This chapter helps consider factors related to the promotion of mental wellbeing and the prevention of mental health problems. It provides easy access to nationally available topic focused information, guidance and knowledge. The chapter text aims to be plain English and ready to be cut and pasted. The numerous links to external sites should all be current, relevant, and provide access to material that contributes to the JSNA process.

One aim of a JSNA is to understand the determinants of health in an area and consider social and contextual factors that affect mental health, such as employment, crime, safety and housing. The mental health of each individual is influenced by their social setting, such as having the ability to earn enough money and feeling part of a community. This chapter considers these determinants which lead to unfair and avoidable differences in health within and between populations.

Understanding these social factors in a local area can help to quantify levels of risk, protection and resilience within a community. It can help to identify vulnerable groups and consider what interventions could help to reduce vulnerability and develop resilient communities. Greater community resilience has the potential to:

reduce the prevalence of mental health problems

increase the prevalence of good mental health

improve recovery and support for individuals who have become unwell

Understanding these 'place' effects on health, and particularly the effect of measures of deprivation, may have been considered elsewhere within the wider JSNA process. This should be drawn upon and used to consider which factors are important to mental health.

Interventions which affect the social determinants of mental health require joint working and collaboration across a range of partners, for example the education sector working with health and wellbeing boards.

Type of questions a JSNA could address include

what local social, economic and other factors encourage good mental health?

what local social, economic and other factors damage mental health?

how are these changing over time?

how do they affect different groups of people or cause inequalities?

what are the community's main assets and how strong are social networks?

what do local people feel about the area and what are they concerned about?

how do these wider factors affect the need for mental health services?

how can these wider influences on health be tackled by prevention initiatives?

2. Deprivation and inequality

It is well established that deprivation (a lack of money, resources and access to life opportunities) or being in a position of relative disadvantage (having significantly less resource than others) is associated with poorer health, including mental health.

2.1 Overview

Mental health is closely related to many forms of inequality, with a particularly pronounced gradient for severe mental illness. The prevalence of psychotic disorders among the lowest fifth of household income is 9 times higher than in the highest and double the level of common mental health problems between the same groups.

Deprivation is about more than lack of money. It can include lack of access to resources such as adequate housing and exposure to negative stressors such as violence, crime or lack of public green space. A growing body of evidence suggests the relationship between deprivation and mental health is not just about absolute lack of resource for individuals. Populations with large differences in wealth and resource between individuals are associated with higher levels of poor health and mental health problems for the population as a whole.

2.2 Data sources

Metrics in the profiling tool relating to deprivation and inequality are:

children in income deprivation (county and UA)

income deprivation affecting children index (UK) (ward)

deprivation score: IMD 2015 (county and UA, district and UA, CCG, GP, ward)

Other important data sources include:

Local data

Local analyses will be able to draw upon additional local data about deprivation and inequalities to further profile risk and map inequalities. For example, use of different services (primary care, accident and emergency ( A&E) and mental health services) by local deprivation measures.

2.3 Evidence and further information

The topic specific sections which follow will include additional relevant information on:

poverty and financial security

housing and homelessness

education and lifelong learning

employment and working conditions

crime and justice

community wellbeing

social capital

The following documents and supporting materials are useful sources of further information on this topic:

Health Matters: reducing health inequalities in mental illness is a publication by Public Health England describing the drivers of inequalities associated with mental health particularly in understanding the social inequalities and disadvantages in severe mental health illness.

LGA: Being mindful of mental health: The role of local government in mental health and wellbeing sets out the important role councils play in supporting the mental wellbeing of their communities, including the Local Government Association's ( LGA) vision of what a 'mentally healthy' place looks like.

The Royal Town Planning Institute's Poverty, place and inequality sets out a place-based approach to addressing poverty and inequality by understanding how local environments shape people's behavior and enhance wellbeing.

Marmot review report - Fair society, health lives 2010 proposes an evidence-based strategy to address the social determinants of health which can lead to health inequalities.

3. Poverty and financial insecurity

Low income and debt are risk factors for mental illness. Personal and family financial security is a protective factor. Improved understanding of financial circumstances can help identify and target vulnerable groups and support the recovery of people with mental health problems.

3.1 Overview

Poverty can be both a causal factor and a consequence of mental ill health. Across the UK, both men and women in the poorest fifth of the population are twice as likely to be at risk of developing mental health problems as those on an average income. The cumulative effects of poverty are present throughout the life course, starting before birth and continuing into older age.

Unmanageable financial debt is associated with poorer mental health,. A quarter of people experiencing common mental health conditions also have financial problems, 3 times more than the general population. Half of adults with a debt problem also have a common mental health condition. A survey of 5,500 people with mental health problems found that 86% of respondents said their financial situation had made their mental health problems worse.

Mind has a dedicated section on its website outlining the relationship between money and mental health problems. Mental health problems can effect an individual's motivation and ability to attend work or rehabilitation programmes which can affect income and recovery.

Additionally, a number of mental health conditions can lead to periods of impulsivity in spending, and anxiety is often exacerbated by money concerns. When people do not have enough money they may struggle to afford 'essentials' such as heating, housing, food and medication. Social activity is often an area where people look to save money, which can lead to increased social isolation and have a negative effect on people's relationships and mental health.

Since 2008, the UK has experienced the effects of a prolonged economic downturn. Policy decisions in response to the economic downturn have resulted in reductions in some public spending, and there is concern that this could negatively affect the mental health of the population[footnote 10].

3.2 Data sources

Metrics in the profiling tool relating to poverty and financial security include:

fuel poverty (county and UA, district and UA)

housing affordability (county and UA)

Other important data sources include:

3.3 Local data

Local analyses may be able to draw upon additional data about financial circumstances and associated supportive interventions. Local Citizens Advice Bureaus, Credit Unions, food banks and relevant local charities may hold data.

3.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Citizens Advice: A debt effect? How is unmanageable debt related to other problems in people's lives? investigates the relationship between high levels of debt and a range of wider issues including unemployment, low pay, physical health problems and poor mental health.

Joseph Rowntree Foundation's We can solve poverty in the UK sets out recommendations on actions to solve poverty.

The Mental Health Foundation's Poverty and mental health review examines the relationship between poverty and mental health.

Money and mental health policy institute's ' The missing link - how tackling financial difficulty can boost recovery rates in IAPT' puts forward the case that the adult improving access to psychological therapies ( IAPT) programme should seek to recognise, and develop ways to mitigate, the effects of financial difficulty.

PHE's Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health includes a section on the effectiveness of providing debt advice to encourage mental health.

4. Housing and homelessness

Housing is critical to the prevention of mental health problems and the promotion of recovery[footnote 11]. Homelessness and poor quality housing are risk factors for mental health problems. Stable, good quality housing is a protective factor for mental health and can be a vital element of recovery.

Overview

Insecure, poor quality and overcrowded housing causes stress, anxiety, and depression, and exacerbates existing mental health conditions[footnote 12] . 19% of adults living in poor quality housing in England have poor mental health outcomes[footnote 13]. For example, adolescents living in cold housing are at a significantly greater risk of developing multiple mental health conditions[footnote 14]. A cold home also contributes to social isolation which may be a particular issue for older people[footnote 15].

Everybody who experiences homelessness will feel stress and anxiety, and many report depression[footnote 13]. Mental health problems among people experiencing homelessness are more prevalent than in the general population, particularly among people caught in the 'revolving door', between hostels, prison, hospitals and the streets[footnote 16]. Compared with the general population, homeless people are twice as likely to have a common mental health condition, and psychosis is up to 15 times more prevalent[footnote 11]. They are also over 9 times more likely to complete suicide[footnote 17] . People experiencing homelessness find it difficult to access health services, including mental health care[footnote 18] ,[footnote 19] .

4.1 Data sources

Metrics in the profiling tool relating to housing and homelessness include:

statutory homelessness (county and UA, district and UA, region)

fuel poverty (county and UA, district and UA)

housing affordability ratio (county and UA)

landlord home repossessions (district and UA)

stable and appropriate accommodation for adults in contact with mental health services (County and UA)

Other important data sources include:

4.2 Local data

Local analyses may be able to draw additional data about housing policy likely to have a beneficial effect on population mental wellbeing. This may include metrics on topics such as: numbers of supported accommodation places available, rental stability and security, affordable housing units planned/built in last year(s) and numbers of people with mental illness in receipt of direct payments or services to support them remaining in their own home. There may also be locally conducted surveys to assess housing needs and data from third sector organisations working with people who are homeless.

4.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Centre for Mental Health's More than shelter presents a series of important themes for consideration in the future development of supported accommodation for adults with severe mental health problems, including those with multiple needs and substance misuse and those facing homelessness.

Homeless link website provides resources including audit tool for needs assessment and a prevention opportunities mapping and planning toolkit ( PrOMPT) which supports gathering information that can be used to redesign services and improve prevention.

The Mental Health Foundation's Mental health and housing report on types of supported accommodation that successfully meet the needs of people with mental health problems - to recommend effective housing solutions.

PHE's Homelessness: applying all our health provides an overview of the issues that are associated with homelessness and highlights interventions that can be implemented at population, community, family and individual levels.

PHE's Homes for health provides resources on housing conditions, suitability and homelessness, and building healthy communities to help local authorities, health and social care commissioners and decision makers make plans to improve health and wellbeing through the places people live.

PHE's Spatial planning for health: an evidence resource for planning and designing healthier places Community based provides public health planners and local communities with evidence informed principles for designing healthy places.

5. Education and lifelong learning

Education is an important determinant of later health and wellbeing. It improves peoples' life chances, increases their ability to access health services and enables people to live healthier lives.

Overview

Education develops skills that help people to function and make decisions in life. It increases peoples' ability to get a job and avoid living in poverty. It helps people to understand how social and health systems work allowing them to improve their health and wellbeing[footnote 20].

Pupils with emotional and conduct disorders are more likely to fall behind in their learning[footnote 23]. Those not in education, employment or training ( NEET) after the age of 16 are at increased risk of depression and suicide and the damaging effect of unemployment at this stage of life lasts into later life[footnote 24]. Successful interventions exist which reduce the proportion young people who are NEET. These are more likely to be effective if the intervention is early and if they tackle the barriers faced by children and young people in accessing education and training. They must also work across organisational and geographic boundaries[footnote 24].

For adults, lifelong learning opportunities can increase the ability of those with low educational attainment to exert control of their lives[footnote 25]. Participation in adult learning can help encourage wellbeing and protect against age-related cognitive decline in older adults[footnote 26]. Community-based adult education programmes can be a form of social prescribing for mild to moderate anxiety and depression and have been found to reduce symptoms by offering access to social networks and activities[footnote 27].

5.1 Data sources

Metrics in the profiling tool relating to education and lifelong learning include:

school readiness (county and UA)

average attainment 8 scores (county and UA)

GCSEs achieved 5 grades A* to C (ward)

16 to 18 year olds not in education, employment or training (county and UA, region)

Other important data sources include:

5.2 Local data

Additional local data from education providers and local authorities will be available and should be used to gain insights on provision, access and needs in the local area. This could include data on availability of and access to life-long learning.

5.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Department for Education's Mental health and behaviour in schools: departmental advice for school staff gives strategies to encourage resilience and support pupils at risk of developing mental health problems in schools.

Mental Health Foundation's Learning for life: adult learning, mental health and wellbeing outlines evidence for adult learning interventions for anxiety and depression.

Social and emotional wellbeing in primary and secondary education are NICE guidelines to promoting social and wellbeing in children in the educational setting.

PHE's Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health includes sections on the effectiveness of school-based social and emotional wellbeing programmes and programmes to address bullying of young people.

PHE and the Institute for Health Equity's Reducing the number of young people not in employment, education or training (NEET) outlines interventions to reduce the number of young people NEET and evidence for the cost-effectiveness of interventions.

PHE's Supporting mental health in schools and colleges provides a survey and case studies with schools on activities to support pupils' mental health and wellbeing.

6. Employment and working conditions

Stable and rewarding employment is a protective factor for mental health and can be a vital element of recovery from mental health problems. Unemployment and unstable employment are risk factors for mental health problems.

6.1 Overview

There are strong links between employment and mental health. The workplace provides an opportunity to encourage well-being and support people to 'build resilience, develop social networks and develop their own social capital'[footnote 30]. People who are unemployed are between 4 and 10 times more likely to report anxiety and depression and to complete suicide[footnote 31].

Challenges remain for people with mental health problems in gaining and maintaining employment, sometimes because of negative attitudes and stigma, and concerns from employers who know little about mental health. Between 30% and 50% of people with schizophrenia are thought to be capable of work given appropriate support and opportunity, yet only 9% of people with a probable psychotic disorder are working full-time and 19% part-time[footnote 35]. There is an emphasis on the doubling of access to individual placement and support ( IPS) interventions aimed at enabling people with severe mental illness to find and retain employment[footnote 36].

Mental health problems also have a significant effect on employers. Nearly one sixth of the workforce is affected by a mental health condition[footnote 37] and mental health related absences cost UK employers an estimated £26 billion per year[footnote 38] . Employers have a responsibility to provide a healthy workplace[footnote 39]. This can be achieved through providing a culture of participation, equality and fairness and developing the role of line managers[footnote 40],[footnote 41].

6.2 Data sources

Examples of metrics in the profiling tool relating to employment and working conditions include:

employment deprivation (county and UA, district and UA)

allowance and benefits (county and UA, district and UA)

employment of people with a mental illness or learning disability (county and UA)

gap in employment rate for those in contact with secondary mental health services and the overall employment rate (county and UA)

Other important data sources include:

NOMISWEB labour market statistics provided by the Office for National Statistics includes data on benefit claimants, including those recorded as being on benefits due to mental and behavioural disorders.

benefits statistics are also available on Stat-Explore

Public Health England provides assessment of the ROI of interventions to encourage health and wellbeing in the workplace and workplace interventions to prevent stress, depression and anxiety problems

Understanding local needs for wellbeing data from the What Works Centre for Wellbeing provides recommended relevant indicators

6.3 Local data

Additional local data may be available from local authorities, from relevant local agencies and from analysis of ad-hoc surveys which include questions about employment status and mental health state. There may also be local knowledge about changes in large employers and how these relate to employment at a sub-local authority level and data from programmes that support people into employment.

6.4 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

Business in the Community and PHE's Mental health toolkit for employers aimst to help organisations support mental health and wellbeing of employees.

The Centre for Mental Health's Individual placement and support (IPS) outlines the IPS approach, including links to the relevant evidence base and examples of successful implementation.

Department for Work and Pensions' Work, health and disability green paper is a government consultation paper highlighting the important relationship between work and health. Includes proposed improvement strategies.

The Cochrane review's Flexible working conditions and their effects on employee health and wellbeing evaluates the effects of flexible working interventions on the physical, mental and general health and wellbeing of employees and their families.

Mind's mental health at work web resources provide training information and webinars for individuals and employers. Includes resources about supporting staff who are experiencing a mental health problem.

Mental wellbeing at work and workplace health are NICE guidance publications developed to encourage mental wellbeing at work. Recommendations vary according to organisation type and size and links to relevant related guidance are made within the pathway. A comprehensive resource page is also available along with an accompanying guide.

PHE's Commissioning cost-effective services for promotion of mental health and wellbeing and prevention of mental ill health includes sections on the effectiveness of interventions to encourage health and wellbeing in the workplace and prevent stress, depression and anxiety problems.

PHE's Workplace health: applying 'All our health' provides evidence and guidance to help healthcare professionals encourage people to live healthy lifestyles at work. Also includes a wide range of references to relevant NICE publications and sources of employment indicators.

SCIE: Mental health, employment and the social care workforce summarises evidence on what prevents people with mental health problems from working or retaining work in social care and what can be done to enable them to work.

Workplace wellbeing charter is an online resource providing information for workplaces on how to assess and improve their workplace wellbeing.

7. Crime, safety and violence

The relationship between crime and mental health problems is complex. It can also be controversial, as public perception about the relationship can contribute to stigma, discrimination and social exclusion.

Overview

There is high prevalence of mental health needs among people in contact with the criminal justice system. 16% of prisoners report symptoms indicative of psychosis, a much higher proportion than in the general population[footnote 43]. These disorders are more severe and complex[footnote 44], and are often combined with poor physical health and substance misuse. There are high levels of mental health conditions amongst people on probation[footnote 45]. There are also high levels of mental health conditions (including psychosis, antisocial personality disorder and anxiety) among British male gang members[footnote 46].

People in contact with the criminal justice system have substantially more risk factors for suicide (increased prevalence of mental health conditions, substance misuse and socioeconomic deprivation) and are recognised as a priority group in the cross-government suicide prevention strategy[footnote 47]. The risk of suicide is highest in the 28 days following release from prison48. Suicide and self-harm is covered in more depth in Mental health: population factors.

Liaison and diversion services have received strong government backing in recent years[footnote 30]. The ambition is to divert people with mental health and/or substance problems away from custodial settings wherever possible, enable access to health and social care in the community and reduce likelihood of re-offending. Since 2017, parts of England have been testing a new Community Service Treatment Requirement ( CSTR) programme. In some instances where short-term custodial sentences have been ineffective, offenders with mental health, alcohol and substance abuse issues are diverted towards treatment that aims to tackle the root cause of their criminality. The NHS Long Term Plan reaffirms the commitment to expand provision of the scheme[footnote 49].

Many people in contact with justice services with mental health problems will additionally be experiencing other issues such as difficulty accessing good quality homes, employment and income. This may result in their mental health deteriorating. Many have been victims of abuse and crime themselves. Those in prison need to have their needs identified and addressed during their time in prison and support should continue when they return to their local community. The care after custody service, RECONNECT, starts working with people before they leave prison and helps them to make the transition to community-based services by providing the health and social care support they need[footnote 49].

The major determinants of violence are socio-economic factors and substance misuse, whether they occur concurrently with a mental health condition or not[footnote 50]. Violence prevention strategies should include early identification and treatment of substance abuse problems and greater attention to the diagnosis and management of concurrent substance abuse disorders among people with a severe mental illness ( see Mental health: population factors).

Being a victim of crime, or exposure to violent or unsafe environments can increase the risk of developing a mental health problem. The most serious example at a young age is child abuse, which can have a sustained detrimental effect on mental health through to adulthood[footnote 51].

Being a victim of intimate partner violence or domestic abuse increases the risk of mental health problems[footnote 52] and there are high rates of mental health conditions (particularly post traumatic stress disorder( PTSD)) among people who have been raped and among immigrant women who have undergone female genital mutilation[footnote 53].

7.1 Data sources

Examples of metrics in the profile relating to safety, violence and crime:

first time entrants to the Youth Justice System (county and UA)

re-offending levels (county and UA, district and UA)

violent crime (including sexual violence) - violence offences (county and UA, district and UA)

Other important data sources:

National Drug Treatment Monitoring Service (NDTMS) provides data on adult and children and young people's community substance misuse treatment services including referrals from criminal justice pathways. NDTMS also provides data across the adult prison and CYP secure estates in England. (NB: aggregate data prison-level data are not in public domain).

Ministry of Justice (MoJ) Prison Population Data: prison population demographics and population flows includes data provided directly from prisons and other datasets including ONS data.

Health and Justice Indicators of Performance (HJIPs - not in public domain) - this NHS data asset has been co-produced with PHE and NOMS and collects data on a broad range of health needs and health services including prisoner mental health.

Relevant indicators are recommended in the What Works Centre for Wellbeing's Understanding local needs for wellbeing data.

7.2 Local data

Local areas may be able to access relevant data which are not nationally available, eg for domestic abuse, additional local data may be obtainable from the police, Multiagency Risk Assessment Conferences ( MARAC) and from services that provide interventions. Local data may be available directly from the prisons, probation services, and from youth offending services, including statistics from initial assessments about mental health and drug and alcohol use.

Depending on the local population and data availability, areas may choose to focus their needs assessment work on specific topics, for example gang culture, cyber bullying, female genital mutilation, slavery, child exploitation and forced prostitution. Local areas may choose to include more detailed information on prison populations if they have a prison within their area.

7.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic.

Mental Health Crisis Care Concordat website aims to improve responses to people in mental health crisis, many of whom come into contact with the police. It brings major partners together to agree shared actions.

Police and Crime Bill contains provisions that prohibit people aged under 18 being held in police custody under the Mental Health Act, ensures adults are only detained in exceptional circumstances and also reduces the maximum permitted detention time to 24 hours.

NHS England's Liaison and diversion resources: offers a wide range of information on the liaison and diversion approach, including resources for services to use.

NICE guideline on Mental health of adults in contact with the criminal justice system covers assessing, diagnosing and managing mental health problems in adults (aged 18 and over) who are in contact with the criminal justice system.

Victims strategy offers a cross-governmental strategic framework to improving support for victims or witnesses to crime during their journey through the justice system. Often traumatic experiences can leave physical and mental scars that can endure many years after the events.

Understanding victims of crime by Victim Support offers quantitative and qualitative look at the effect of crime and the victims' needs, identifying the effects of victimisation and recognise victims' expressed needs.

PHE's annual health and justice report focuses on health in prisons and other places of detention.

Rebalancing act produced by Revolving Doors Agency and PHE, working with the Home Office and NHS England, supports collaborative work to improve health, reduce offending and health inequalities among people in contact with the criminal justice system.

Standards for Prison Mental Health Services is a framework by which to assess the quality of prison mental health services through a process of self and peer review.

8. Community wellbeing and social capital

Good mental health and wellbeing is an important health outcome in its own right and can improve resilience to mental and physical illness. Measures of good social capital are associated with better population-level health and wellbeing.

8.1 Overview

Mental wellbeing is more than the absence of mental illness. It is linked with an individual's emotional, physical and social wellbeing and the wider social, economic, cultural and environmental conditions in which they live. Mental wellbeing is a combination of an individual's experience (such as happiness and satisfaction) and their ability to function as both an individual and as a member of society[footnote 56]. It includes sense of control, resilience, self-efficacy and social connectedness.

Mental wellbeing is of particular importance to children and young people, influencing the way in which they cope with important life events. Children and adults with better mental wellbeing are likely to deal better with stressful events, recover more quickly from illness, and be less likely to put their health at risk[footnote 57].

The mental wellbeing of individuals is influenced by factors at a community level such as social networks, sense of local identify, levels of trust and reciprocity and civic engagement. The benefit of this "social capital" can be felt at an individual level (for example, through family support) or at a wider collective level (for example, through volunteering). Social capital is associated with values such as tolerance, solidarity or trust. These are said to be beneficial to society and are important for people to be able to cooperate[footnote 58].

Whilst disadvantaged communities have higher health need, they may also have assets within the community that can improve health and build resilience[footnote 59]. Community assets improve the health and the quality of the community. They include physical assets such as public green space, play areas and community buildings and social assets such as volunteer and charity groups, social networks and the knowledge and experiences of local residents. These assets have potential to protect and increase community wellbeing and thus strengthen resilience.

The wellbeing of young people is increasingly influenced by modern day technology. The significance of technology in peoples' lives have led to debate on the effects of social media on young people's mental and physical wellbeing[footnote 60]. The effects of substituting social media activity for other forms of social interaction is not fully understood. Cyberbullying is increasingly an issue in young people (see Children and young people).Understanding the use of this sometimes 'problematic' technology may help to manage the risks and instead be used to help improve wellbeing and health[footnote 61].

8.2 Data sources

Examples of metrics in the profiling tool relating to individual and community wellbeing include:

wellbeing in 15 year olds (county and UA)

enough physical activity (county and UA, district and UA)

self-reported wellbeing (county and UA)

Other important data sources include:

Local data

Local areas may focus on collection of metrics around wellbeing and community assets to help understand local resilience. This may include local surveys to measure social capital including aspects of trust, group membership, social connections and participation in decision making processes. Inclusion of locally collected metrics could form an important element of a JSNA.

Guidance documents on potential metrics include:

8.3 Evidence and further information

The following documents and supporting materials are useful sources of further information on this topic:

9. References

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The purpose of the mental health and wellbeing JSNA toolkit is to support people developing the mental health and wellbeing content of their local joint strategic needs assessment. This chapter helps consider factors related to the promotion of mental wellbeing and the prevention of mental health problems. It provides easy access to nationally available topic focused information, guidance and knowledge.

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Your thoughts on working with substance abuse/dependency: I would work with them but be sure to set boundaries, and reinforce them where necessary, for example, making it very clear that sessions would not go ahead if they were under the influence of a substance. I would discuss things with my supervisor and if things got too much for me to handle, I might discuss the idea of a referral.
Consider ethics & safe practice: I think it would be wise to do some CPD and reading into working with substance abuse before taking on clients with a moderate or severe case as this could be outside of competency otherwise. You'd need to talk to your supervisor about any concerns and also make sure that you were resilient enough to handle the client, as well as fostering your own self-care i.e. have you had difficult experiences with it yourself or a loved one and would that get in the way of you providing a good standard of service? You would also need to be aware of legislation such as the mental health act and road traffic act.
Consider assessment: You may wish to explore the possibility of underlying mental health concerns that have triggered the substance abuse, and in this case discuss this with your client verbally, and/or carry out a PHQ9/GAD7 assessment to see whether low mood or anxiety could be perpetuating the symptoms. It would be helpful to get as much information as possible in order to give the client the best help and support.
What would you experience in the room: The client may come in under the influence of a substance and have the courage and wisdom to manage that, they may also be quite quiet, and up and down.

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An example of a theoretical description of abnormality is the one suggested by Marie Jahoda in 1958.

She suggested that there were 6 criteria that needed to be fulfilled for ideal mental health ('normality'). The six criteria were a positive attitude towards the self, self-actualisation, autonomy, resistance to stress, environmental mastery and an accurate perception of reality. These are outlined below:
Positive attitude towards the self
This is linked to the individual's level of self-esteem. For ideal mental health the positive attitude should be at a good level, so that the individual feels happy with themselves.
Self-actualisation
Self-actualisation is being in a state of contentment, feeling that you have become the best you can be.
Autonomy
This is having the independence and self-reliance. The ability to function as an individual and not depending on others.
Resistance to stress
This criteria is that an individual should not feel under stress and they should be able to handle stressful situations competently.
Environmental mastery
Having environmental mastery means that the person can adapt to new situations and be at ease at all situations in their life.
Accurate perception of reality
This criteria is focused on how the individual sees the world around them and to achieve ideal mental health they should have a perspective that is similar to how others see the world. This is focused very much on the distortions of thinking that some people, e.g. people with schizophrenia, may experience.

Jahoda stated that for ideal mental health to be achieved the individual should experience all of these criteria for optimum ideal mental health and that if some are not fulfilled the person will experience difficulties.
Strengths of the definition
Focused: A strength is that this definition allows for an individual who is struggling to have targeted intervention if their behaviour is not 'normal'. For example, their distorted thinking could be addressed to help their behaviour become normal, as if their thinking is biased then their behaviour will be too.

Positive: This definition focuses on what is helpful and desirable for the individual, rather than the other way round

Achievement of goals: This idea allows for clear goals to be set and focused upon to achieve ideal mental health, and, in Jahoda's opinion, to achieve normality.
Weaknesses of the definition
Feasibility: The criteria outlined by Jahoda makes ideal mental health (normality) practically impossible to achieve. This means that the majority of the population, using this definition, would be abnormal.

Ethnocentrism: The criteria of autonomy makes the collectivist cultures, where the greater good and helping / relying on others is encouraged, seem abnormal. As most western cultures are individualist the criteria outlined by Jahoda seem a reasonable fit, but non-western cultures cannot relate to the criteria she outlines. This means that the definition is not global.

Subjectivity: The criteria that Jahoda stipulates are vague and are therefore very difficult to measure. This makes the decision as to whether someone fulfils the criteria difficult to make.

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Deviation from Ideal Mental Health | Psychology | tutor2u

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An example of a theoretical description of abnormality is the one suggested by Marie Jahoda in 1958. She suggested that there were 6 criteria that needed to be fulfilled for ideal mental health ('normality'). The six criteria were a positive attitude towards the self, self-actualisation, autonomy, resistance to stress, environmental mastery and an accurate perception of reality.

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Challenging the culture of psychiatric diagnosis and exploring trauma informed alternatives. "The problem is in the assumption we're broken."

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"Mental health is a state of wellbeing in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make contributions to his or her community."

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Good mental health is not simply the absence of diagnosable mental health problems, although good mental health is likely to help protect against development of many such problems.

Good mental health is characterised by a person's ability to fulfil a number of key functions and activities, including:

the ability to learn

the ability to feel, express and manage a range of positive and negative emotions

the ability to form and maintain good relationships with others

the ability to cope with and manage change and uncertainty.

See our top 10 tips for looking after your mental health

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Good mental health is not simply the absence of diagnosable mental health problems, although good mental health is likely to help protect against development of many such problems. Good mental health is characterised by a person's ability to fulfil a number of key functions and activities, including: the ability to learn the ability to feel, express and manage a range of positive and negative emotions the ability to form and maintain good relationships with others the ability to cope with and manage change and uncertainty.

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Positive mental health is not just the absence of any mental concerns, but is characterised by a persons ability to learn and engage in certain activities such as being able to express and manage positive and negative emotions, form and maintain healthy relationships with others and be able to cope with change and uncertainty.

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Think about it. When a person behaves oddly or deviates from the societal standards of normality, we address him/her in so many ways - depressed, anxious, moody, suicidal, and the list goes on.

But how often do we hear ourselves categorizing the 'mentally healthy' people as happy, very happy, or well-balanced?

Mental health researchers across the world agree that mental illness is often overindulged in our society, whereas mental health gets less attention than it should. Gordon Allport (1937) mentioned in his studies that mental health and illness are not two independent constructs. They are two poles of a linear sequence and keep moving throughout the lifetime.

According to Allport, a fully developed and well-functioning individual manifests the following features:

A variety of interests and the zeal to pursue them.

The ability to accomplish daily responsibilities, including self-care.

A mature insight into his internal and external worlds.

Failure to perceive or exhibit any of the three qualities indicate a deviation from optimal functioning and would mark a shift from the 'healthy' end of the continuum to the 'unwell' end of it. This article is a short but in-depth exploration of the mental health continuum model that studies human psyche and psychological disturbances as a unified concept (Frisch, Cornell, Villanueva, & Retzlaff, 1992).

Before you read on, we thought you might like to download our 3 Positive Psychology Exercises for free. These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

What is the Mental Health Continuum? (Definition)

The mental health continuum is a range having mental health and mental illness at the two extreme ends. Depending on the internal and external faculties of a person at any time, he can lie at one point of the continuum and shift position as his situation improves or deteriorates.

There are distinct markers within the mental health continuum:
The Healthy Point
People who lie at this point are generally satisfied and happy in their lives. They are emotionally well-balanced, stable, and goal-oriented.
The Problem Point
This is the mid-range of the continuum. People who lie at this point may show some distress and inability to cope, but are capable of performing daily life functions.
The Disorder Point
This is the end of the continuum, and as the name suggests, people falling under this category are unable to cope with stress and exhibit significant changes in their thoughts, behavior, and actions.

How is it Used?

Mental health continuum model projects the human mind on a continuous linear perspective. It helps in recognizing specific behavioral patterns that may need attention and suggests ways of dealing with the adversities that cause trouble.

The mental health continuum is often used in association with the BETLS (The Behavior, Emotions, Thoughts, Learning, and Social Relationship) model and is widely used for:

Identifying the underlying causes of impairment in daily life functions.

Gathering information about the different mental health states of a person over time.

Indicating when it would be ideal to seek professional assistance for restoring the mental balance.

Recognizing symptoms of different psychological disorders.

As a reliable self-help tool for professionals at work, the mental health continuum model is a popular choice among leaders and managers of leading organizations today. As a part of organizational psychology, the continuum helps in:

Identifying the sources of stress among employees at all levels.

Encouraging employees to grow a healthy mindset that can help them overcome distress and move to the other end of the continuum.

Maintaining a positive growth mindset among leaders, supervisors, and others in the company.

Understanding how to identify the mental health symptoms in oneself and others.

Learning how to deal with the psychological crises effectively and not allowing them to jeopardize our well-being.

The Short and Long-form Models Explained

The long-form and short forms of mental health continuum (MHC) had been developed as a quantifiable and objective analysis of the mental health continuum model. They are self-assessed questionnaires with items that indicate one's current level of psychological functioning and confirms the implication of the mental health linear model.

The long-form (MHC-LF) was created at first, and it formed the basis of the short-form assessment later.

The items in the MHC-LF and the MHC-SF are categorized into three scales:

The positive emotional well-being scale.

The psychological well-being scale.

The social well-being scale.

The long-form consists of 40 items that assess subjective well-being. The short-form is an abridged version of the MHC-LF that consists of 15 items in total:

Seven statements measuring emotional well-being.

Six three-item scales measuring the six dimensions of Ryff's model of psychological well-being (Ryff, 1989).

Five three-item scales for assessing the five dimensions of Keyes' model of social well-being (Keyes, 1998).

Both the tests have high validity and internal consistency reliability, making its usefulness unquestionable for assessing mental health and mental health problems. The long and short forms of the mental health continuum model are useful for the neuropsychological understanding of mental health disorders and their impact on our daily lives (Keyes & Simoes, 2012).

For example, studies on GAD patients and panic attack victims revealed that encouraging them to take the assessments positively impacted the prognosis and reduced the risk of premature mortality (Keyes, Dhingra, & Simoes, 2010).

The forms are successfully used across different healthcare, academic, and disability sectors today. Below are brief illustrations of the two mental health continuum forms. You can learn more about them from the links below.

Mental Health Continuum Long Form - MHC-LF

How strongly do you agree or disagree with each of the following statements?

Access the full MHC-LF.

Mental Health Continuum Short Form - MHC- SF

During the past month, how often have you felt the following?

Everyday

Almost everyday

2-3 times a week

About once a week

Once or twice a week

Never

Happy
Interested
Satisfied
Part of your community
Important to your society

Your society is a good place and is changing for the better.
People are generally good.
You understand how society works.
You like most parts of your personality.
You feel comfortable performing all the daily responsibilities.

You have loving and trusting relationships with others.
Your experiences helped you to become a good person.
You are confident to express your ideas.
You feel a sense of direction in your life.

A Look at the Mental Health Continuum Diagram

We experience stress every day, and sometimes it does take a toll on our happiness and well-being. Many of us succeed in overcoming the anxiety and bounce back to life, and their inner balance remains intact. But some unpleasant encounters dishevel the mind, and we might need a little support at those times to get back on our feet.

As the primary responder to stress, we should pay equal importance to the daily struggles as we pay to the more significant adversities. For example, divorce, death, or financial crisis are undoubtedly substantial stressors that can alter our mental stability in a day. But equally potential stressors lie in daily tidbits such as regular arguments with spouse, awkward commuting hazards, an unpleasant work environment, etc..

The theory of MHC states that while identifying which point we lie at the present moment, we must consider all the little things that upset us, and work on minimizing them altogether. The continuum describes the different mental health conditions along with their physiological effects and suggests ways to improve both.

The diagrammatic representation of MHC depicts:

Healthy and adaptive coping state.

Mild and reversible distress state.

Severe and persistent impairment.

Clinically significant mental disorder.

It is important to remember that we all are capable of moving from one end to the other end of the continuum. Being in the red zone does not imply that we cannot be in the green zone again, and vice versa. Below is a brief description of the main features of the mental health continuum model, followed by an illustration of the MHC diagram.

Stage

Characteristics

Ways to improve/sustain

Positive, healthy functioning

Stable mood with minimum fluctuations.
Overall calm and peaceful state of mind.
Contentment with life.
Self-motivated and energetic.
Physically healthy.

Prioritize tasks.
Break problems into smaller chunks and address one at a time.
Maintain a healthy lifestyle.

Neutral, reactive state.

Nervousness and worry.
Vulnerability to stress.
Feeling overwhelmed.
Self-doubt causing anxiety to perform.
Tiredness and lack of energy.

Recognize abilities and limitations.
Get a healthy diet plan and fitness regime.
Engage in more social activities.
Get adequate rest.

Damaged and moderately ill

Persistent sadness and feelings of inadequacy.
Restlessness and irritability.
Lack of motivation to take up new challenges.
Overall feeling of apathy and unexplained fatigue to perform daily duties.
Deterioration in personal and professional relationships.
Substance and drug abuse.

Self-awareness.
Try to get to the root cause of stress.
Seek help.
Get an emotional support system (e.g., family, friends, kids, therapist, colleagues).

Severe mental illness

Extreme anxiety-causing social isolation.
Extreme mood swings.
Sleeping and eating disorders.
Alcohol or drug abuse.
Inability to perform daily responsibilities, including basic self-care.
Marked deterioration in academic or professional achievements.

Go for professional assistance.
Try to stay around others as much possible.
Follow the treatment plan.
Try to regain your previous health routine.

The Mental Health Continuum: From Languishing to Flourishing in Life

Mental health is a state of successful performance of psychological functions, resulting in productive activities, fulfilling relationships with people, and the ability to adapt to change and cope with stress (Jahoda, 1958).

Socialists and clinical psychologists have devoted almost 40 years of research for building a strong groundwork for recognizing mental disorders as 'a syndrome of symptoms' that affects well-being. Mental illness does not mean the absence of mental health; it merely implies that the person, at present, lies at the negative end of the continuum.

As a complement to the mental health continuum model, the 'Languishing vs. Flourishing' perspective came into the picture. Within this perspective, mental health disorder or an overall distressed state is referred to as 'languishing,' whereas, a more positive and content state is called 'flourishing.'

Studies on this model focused on four fundamental aspects:

The prevalence of flourishing and languishing in the overall sample population.

The association of languishing with significant depression and other mental health illnesses.

The relationship between flourishing and happiness and whether one calls for the other.

The understanding of mental health and mental health disorders among the general population.

The languishing vs. flourishing model of mental health became significantly popular after the multiple success of its application across different parts of the world. An experiment on adults aged 25-70 years revealed that participants who fitted the flourishing criteria scored higher on happiness scales and did not show any symptoms for depression or burnout.

On the other hand, cross-examination of individuals whose score fell under the languishing criterion showed that they have underlying depression. The risk of major depression, as revealed in the study, was significantly higher among individuals who lied at the languishing end of the scale.

Furthermore, the descriptive details of the study showed that languishing and depression were associated with personality disintegration, and most people who manifested depressive symptoms were the working adult population.

The Illness-Wellness Continuum

Dr. John Travis (1972) created the Illness-Wellness Continuum, intending to inspire people rather than treat them. He formulated the continuum and a Wellness Inventory with some valuable inputs on how lifestyle modification can bring a positive shift in mindset and move us to the wellness end of the continuum.

The concept focuses on building well-being through responsibility, emotional control, deep insight, and mindful, holistic awareness. From media to spiritual guides, Dr. Travis' work was well-appreciated by all and remained to be one of the most effective life-changing resources that we can find.

The Illness-Wellness Continuum runs on three key concepts of well-being:

Wellness is a process; it is always moving up and down, right, and left. Moving from one paradigm to another does not signify personal achievement or shortcoming, it is a natural process we all go through at some point in life.

Presence of illness does not imply the absence of wellness and vice versa. They differ in degree and do not follow an all-or-none principle.

At any point, we have the potential to push ourselves from illness to wellness.

The Illness-Wellness Model of Travis became famous in 1975 and continues to be the nucleus of many positive psychology interventions and well-being programs.

The Continuum of Care Model

The Continuum of Care Model is an interdisciplinary approach to help individuals and their families who seek mental health assistance. From terminal diseases to childhood problems, and more serious psychological conditions, this pathway benefits individuals by:

Providing opportunities for patient care through partnership in community programs.

Catering to the individual needs of clients and their families.

Ensuring each client gets proper medical assistance when they need.

Providing support to families who have recently lost their loved one.

Offering healthcare services and arranging follow-ups for patients with mental health disorders.

Attending to the quality of services provided by the mental health and care sectors across the region.

The Continuum of Care is a multifaceted model of promoting happiness and well-being across all ages and background. With the broad objective of integrating the healthcare and mental health service sectors, this approach outlines the best in-care and allied services for patients and families (Waikato Health Board, 2004).

It connects a large number of people with painful diseases or other conditions and meets their needs daily. The model encourages patient-doctor relationship and works for bringing change in their mental state that may have been affected by their illness. Successfully used for cancer patients and substance abusers, the Continuum of Care is a praiseworthy initiative to merge health with happiness.

The Be You Mental Health Continuum (incl. PDF)

Be You is an initiative of Beyond Blue, an organization dedicated to providing mental health and volunteering services, both online and in person. With close association to the BETLS (Behaviour, Emotions, Thoughts, Learning, and Social Relationships) theory of mental health, the Be You mental health continuum tool traces specific signs and symptoms of mental disorders from an early stage.

Be You is a favorite choice among educators, childcare supporters, and mental health community workers, as it:

Provides an opportunity to give accessible training and evidence-based information to students and parents about learning difficulties and overall academic performance.

Helps them understand the best ways to deal with children coming from demanding and stressful surroundings.

Organizing mental health records in an accessible directory format and using them when required.

Spreading awareness of mental health and well-being among parents.

Providing consultations and support services to children with a learning disability.

The Be You continuum can trace and distinguish mild, moderate, and severe symptoms of mental illness, making it easy for professionals to plan the intervention strategies. It is a noble initiative of bringing together schools, childcare, medical services, and the mental health sector, with the unified aim to promote well-being and happiness among children.

You can learn more about the Be You mental health continuum and download the PDF.

A Take-Home Message

Mental well-being begins with a strong relationship to the self. A healthy and happy person always feel safe to be around himself. Acknowledging the presence of any tension, worries, or overwhelming emotions can go a long way in developing a deeper and more meaningful connection to the self.

The key takeaway of the concept of mental health continuum is that human minds are always moving. We have the potential to drive ourselves from the negative to the not-so negative, and finally to the positive end of the continuum.

The mere transformation that happens during this shift can change our mindset and fill us with positive life energy. So, let us use the continuum to know ourselves, listen to ourselves, and push ourselves toward a happier and more content life.

We hope you enjoyed reading this article. Don't forget to download our 3 Positive Psychology Exercises for free.

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What is the Mental Health Continuum Model?

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Think about it. When a person behaves oddly or deviates from the societal standards of normality, we address him/her in so many ways - depressed, anxious, moody, suicidal, and the list goes on. But how often do we hear ourselves categorizing the 'mentally healthy' people as happy, very happy, or well-balanced?

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A scale that has mental health at one end and mental illness at the other. It has different points on it:
The Healthy Point - Individuals at this point are generally happy, emotionally stable, well-balanced and goal oriented. They have interests that they pursue.
The Problem Point - Individuals here may have some distress and inability to cope but can still manage to do their daily tasks.
The Disorder Point - People here are unable to cope and show signs of significant changes in their thoughts, actions and behaviour.
It helps to identify problematic behavioural patters and suggests ways of managing them.

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Protects vulnerable people against harm, abuse and neglect. This includes making sure individuals are safe to work with clients and have no history of abuse etc.

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The Mental Capacity Act is designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over.

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A law that tells people with mental disabilities and mental/personality disorders what their rights are, such as if they've been detained.

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1) A young male Asian client has been referred for counselling by his GP and discloses only physical symptoms to you. What cultural implications might you have to be aware of when counselling this client?
2) What are three things you could do to improve your cultural competence?
3) How do Northern European and Eastern countries' prioritization of social and individual welfare differ from that of Britiain?
4) What does the Equality Act provide people with?
5) What does the Mental Health Act provide people with?

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Provides people with legal protection against discrimination based on their gender, religion, sexual orientation, marital status, race, age or disability.

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- Risk assessment (Plan, Stress, Pain, Access to Help/Coping, History of Suicide Attempts)
- Low, medium, high risk protocols.
- RAID team (Rapid, Assessment, Interface, Discharge)
- Legislation (the laws we have to abide by as counsellors)

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Chapter 17

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Good Counsellors: Maintain boundaries, respect clients, are steady and self-assured/aware, do not exploit clients, do not over-share, do good, don't do harm, are honest, humble and up-front, have integrity, work within their competence, are wise and think ahead so that most outcomes can be planned for or managed.

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Ethics: Moral principles that define how we react to certain situations. A branch of philosophy that determines what is right and wrong and moral concepts.
Principles: Fundamental truths that serve as the foundation for a belief, behaviour or chain of reasoning.

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Issues with increased government control over counselling:

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Issues with increased government control over counselling:

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Breach of human rights
Slippery slope to them having total control
Decrease in quality of service due to funding issues, time constraints, increased waiting lists etc
Less ways for people to access counselling so less likely to try.

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Discussed moral/ethical dilemmas e.g. trolley problem.
Talked about the history of counselling.
Discussed ethical issues with online counselling e.g. privacy, data protection, tech issues.

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This is the full text of the Ethical Framework. Follow the link in each section for additional information, FAQs and resources.

All BACP members must work in accordance with the Ethical Framework. You commit to complying with the Framework when you join or renew your membership and it is the main point of reference for decisions in professional conduct hearings.

You should read it, and understand its main principles and points, before working with clients. It's much better to build the Ethical Framework into your practice to help you face challenges and issues rather than just turning to it if something goes wrong.

It has three main sections:

Our commitment to clients provides a summary of working to professional standards and building an ethical relationship

Ethics specifies the values, principles and personal moral qualities that inform our work and underpin supervision

Good practice considers the application of our commitments to clients and ethics to our practice

Our commitment to clients

1. Our ethics are based on values, principles and personal moral qualities that underpin and inform the interpretation and application of Our commitment to clients and Good practice.

Values

2. Values are a useful way of expressing general ethical commitments that underpin the purpose and goals of our actions.

3. Our fundamental values include a commitment to:

respecting human rights and dignity

alleviating symptoms of personal distress and suffering

enhancing people's wellbeing and capabilities

improving the quality of relationships between people

increasing personal resilience and effectiveness

facilitating a sense of self that is meaningful to the person(s) concerned within their personal and cultural context

appreciating the variety of human experience and culture

protecting the safety of clients

ensuring the integrity of practitioner-client relationships

enhancing the quality of professional knowledge and its application

striving for the fair and adequate provision of services

4. Values inform principles. They become more precisely defined and action-orientated when expressed as a principle.

Principles

5. Principles direct attention to important ethical responsibilities. Our core principles are:

Being trustworthy: honouring the trust placed in the practitioner

Autonomy: respect for the client's right to be self-governing

Beneficence: a commitment to promoting the client's wellbeing

Non-maleficence: a commitment to avoiding harm to the client

Justice: the fair and impartial treatment of all clients and the provision of adequate services

Self-respect: fostering the practitioner's self-knowledge, integrity and care for self

6. Ethical decisions that are strongly supported by one or more of these principles without any contradiction with the others may be regarded as well-founded.

7. However, practitioners may encounter circumstances in which it is impossible to reconcile all the applicable principles. This may require choosing which principles to prioritise. A decision or course of action does not necessarily become unethical merely because it is controversial or because other practitioners would have reached different conclusions in similar circumstances. A practitioner's obligation is to consider all the relevant circumstances with as much care as possible and to be appropriately accountable for decisions made.

Personal moral qualities

8. Personal moral qualities are internalised values that shape how we relate to others and our environment. They represent a moral energy or drive that may operate unconsciously and unexamined. This moral energy or drive is ethically more beneficial when consciously examined from time to time and used to motivate our ethical development or shape how we work towards a good society.

9. 'Personal moral qualities' are a contemporary application of 'virtues' from moral philosophy.

10. The practitioner's personal and relational moral qualities are of the utmost importance. Their perceived presence or absence will have a strong influence on how relationships with clients and colleagues develop and whether they are of sufficient quality and resilience to support the work.

11. High levels of compatibility between personal and professional moral qualities will usually enhance the integrity and resilience of any relationship.

12. Key personal qualities to which members and registrants are strongly encouraged to aspire include:

Candour: openness with clients about anything that places them at risk of harm or causes actual
harm

Care: benevolent, responsible and competent attentiveness to someone's needs, wellbeing
and personal agency

Courage: the capacity to act in spite of known fears, risks and uncertainty

Diligence: the conscientious deployment of the skills and knowledge needed to achieve a
beneficial outcome

Empathy: the ability to communicate understanding of another person's experience from that
person's perspective

Fairness: impartial and principled in decisions and actions concerning others in ways that promote equality of opportunity and maximise the capability of the people concerned

Humility: the ability to assess accurately and acknowledge one's own strengths and weaknesses

Identity: sense of self in relationship to others that forms the basis of responsibility, resilience and motivation

Integrity: commitment to being moral in dealings with others, including personal straightforwardness, honesty and coherence

Resilience: the capacity to work with the client's concerns without being personally diminished

Respect: showing appropriate esteem for people and their understanding of themselves

Sincerity: a personal commitment to consistency between what is professed and what is done

Wisdom: possession of sound judgement that informs practice

Conclusion

13. The challenge of working ethically means that practitioners will inevitably encounter situations that require responses to unexpected issues, resolution of dilemmas, and solutions to problems. A good understanding of the ethics that underpin our work is a valuable resource which is helpful in making significant decisions. The use of an ethical problem-solving model and discussion about ethics are essential to good practice. This Ethical Framework is intended to assist practitioners by directing attention to the variety of ethical factors that may need to be taken into consideration and to identify alternative ways of approaching ethics that may prove more useful.

14. No statement of ethics can eliminate the difficulty of making professional judgements in circumstances that may be constantly changing and full of uncertainties. By accepting this statement of ethics, members and registrants of the British Association for Counselling and Psychotherapy are committing themselves to engaging with the challenge of striving to be ethical, even when doing so involves making difficult decisions or acting courageously.

1. As members of the British Association for Counselling and Psychotherapy (BACP) we are committed to sustaining and advancing good practice.

2. This section of the Ethical Framework looks behind Our commitment to clients and Ethics to consider their implications for good practice in more detail.

3. It sets out what can be expected of all members and registrants of BACP as practitioners providing therapeutically-informed services, particularly coaching, counselling, pastoral care, psychotherapy and using counselling skills. This includes being a supervisor, trainer, educator of practitioners, or researcher of any aspect of the counselling professions. Trainees will fulfil all the commitments to clients within the Ethical Framework when working with members of the public as their clients. Good practice point 81 sets out the commitments for working with other trainees to learn new knowledge and skills.

4. As members and registrants of BACP, we have committed ourselves to the principles and values set out in this Ethical Framework and recognise that our membership or registration may be at risk if we fail to fulfil our commitments.

5. Our responsibilities are set out as full or qualified obligations. We are fully and unconditionally committed to fulfilling a specific requirement of Good practice where we state 'we will...' or 'we must...'. Where we consider a requirement may need to be varied for good ethical reasons, we state that 'we will usually...'.

6. We are committing ourselves to being openly accountable and willing to explain how we have implemented any of these obligations to people with a valid interest in our work.

7. We will make each client the primary focus of our attention and our work during our sessions together.

8. Any professional or personal interests that conflict with putting a client's interests first will be carefully considered in consultation with a supervisor, an independent experienced colleague or, when appropriate, discussed with the client affected before services are offered.

9. We will give careful consideration to how we manage situations when protecting clients or others from serious harm or when compliance with the law may require overriding a client's explicit wishes or breaching their confidentiality - see also 10, 55 and 64.

10. In exceptional circumstances, the need to safeguard our clients or others from serious harm may require us to override our commitment to making our client's wishes and confidentiality our primary concern. We may need to act in ways that will support any investigations or actions necessary to prevent serious harm to our clients or others. In such circumstances, we will do our best to respect the parts of our client's wishes or confidences that do not need to be overridden in order to prevent serious harm.

11. We share a responsibility with all other members of our professions for the safety and wellbeing of all clients and their protection from exploitation or unsafe practice. We will take action to prevent harm caused by practitioners to any client - see also 24.

12. We will do everything we can to develop and protect our clients' trust.

13. We must be competent to deliver the services being offered to at least fundamental professional standards or better. When we consider satisfying professional standards requires consulting others with relevant expertise, seeking second opinions, or making referrals, we will do so in ways that meet our commitments and obligations for client confidentiality and data protection.

14. We will keep skills and knowledge up to date by:

a. reading professional journals, books and/or reliable electronic resources
b. keeping ourselves informed of any relevant research and evidence-based guidance
c. discussions with colleagues working with similar issues
d. reviewing our knowledge and skills in supervision or discussion with experienced practitioners
e. regular continuing professional development to update knowledge and skills
f. keeping up to date with the law, regulations and any other requirements, including guidance from this Association, relevant to our work

15. We will keep accurate records that:

are adequate, relevant and limited to what is necessary for the type of service being provided

comply with the applicable data protection requirements - see Information Commissioner's Office website (www.ico.org.uk).

16. We will collaborate with colleagues over our work with specific clients where this is consistent with client consent and will enhance services to the client.

17. We will work collaboratively with colleagues to improve services and offer mutual support - see 56-59 Working with colleagues and in teams.

18. We will maintain our own physical and psychological health at a level that enables us to work effectively with our clients - see 91 Care of self as a practitioner.

19. We will be covered by adequate insurance when providing services directly or indirectly to the public.

20. We will fulfil the ethical principles and values set out in this Ethical Framework regardless of whether working online, face-to-face or using any other methods of communication. The technical and practical knowledge may vary according to how services are delivered but all our services will be delivered to at least fundamental professional standards or better.

21. We will respect our clients' privacy and dignity.

22. We will respect our clients as people by providing services that:

a. endeavour to demonstrate equality, value diversity and ensure inclusion for all clients
b. avoid unfairly discriminating against clients or colleagues
c. accept we are all vulnerable to prejudice and recognise the importance of self-inquiry, personal feedback and professional development
d. work with issues of identity in open-minded ways that respect the client's autonomy and be sensitive to whether this is viewed as individual or relational autonomy
e. challenge assumptions that any sexual orientation or gender identity is inherently preferable to any other and will not attempt to bring about a change of sexual orientation or gender identity or seek to suppress an individual's expression of sexual orientation or gender identity
f. make adjustments to overcome barriers to accessibility, so far as is reasonably possible, for clients of any ability wishing to engage with a service
g. recognise when our knowledge of key aspects of our client's background, identity or lifestyle is inadequate and take steps to inform ourselves from other sources where available and appropriate, rather than expecting the client to teach us
h. are open-minded with clients who appear similar to ourselves or possess familiar characteristics so that we do not suppress or neglect what is distinctive in their lives.

23. We will take the law concerning equality, diversity and inclusion into careful consideration and strive for a higher standard than the legal minimum.

24. We will challenge colleagues or others involved in delivering related services whose views appear to be unfairly discriminatory and take action to protect clients, if necessary - see 11.

25. We will do all that we reasonably can to ensure that our clients are participating on a voluntary basis. Hesitant clients or clients who feel under pressure from other people or agencies to work with us will have their reservations acknowledged and taken into account in how services are offered.

26. We will work with our clients on the basis of their informed consent and agreement. We recognise that exceptional situations may arise where we may need to prioritise the safety of the client or others over our client's wishes and confidentiality - see 10.

27. Careful consideration will be given to working with children and young people that:

a. takes account of their capacity to give informed consent, considering whether it is appropriate to seek the consent of others who have parental responsibility for the young person, and their best interests
b. demonstrates knowledge and skills about ways of working that are appropriate to the young person's development and how relationships are formed
c. demonstrates a sound knowledge of the law relevant to working with children and young people and their human rights
d. is informed about the current culture and customs that affect parenting/care giving and how children and young people interact with each other and other significant people in their lives.

28. We will give careful consideration to obtaining and respecting the consent of vulnerable adult clients, wherever they have the capacity to give consent, or involving anyone who provides care for these clients when appropriate.

29. Our work with clients will be based on professional partnerships with them that aim to increase their wellbeing, capability and/or performance.

30. We will usually provide clients with the information they ought to know in advance in order to make an informed decision about the services they want to receive, how these services will be delivered and how information or data about them will be protected. Where the urgency or seriousness of the situation requires us to intervene before providing such information, we will do so at the first appropriate opportunity.

31. We will give careful consideration to how we reach agreement with clients and will contract with them about the terms on which our services will be provided. Attention will be given to:

a. reaching an agreement or contract that takes account of each client's expressed needs and choices so far as possible
b. communicating terms and conditions of the agreement or contract in ways easily understood by the client and appropriate to their context
c. stating clearly how a client's confidentiality and privacy will be protected and any circumstances in which confidential or private information will be communicated to others
d. providing the client with a record or easy access to a record of what has been agreed
e. keeping a record of what has been agreed and of any changes or clarifications when they occur
f. being watchful for any potential contractual incompatibilities between agreements with our clients and any other contractual agreements applicable to the work being undertaken and proactively strive to avoid these wherever possible or promptly alert the people with the power or responsibility to resolve these contradictions.

32. We will periodically review each client's progress and, when practicable, seek our client's views on how we are working together.

33. We will establish and maintain appropriate professional and personal boundaries in our relationships with clients by ensuring that:

a. these boundaries are consistent with the aims of working together and beneficial to the client
b. any dual or multiple relationships will be avoided where the risks of harm to the client outweigh any benefits to the client
c. reasonable care is taken to separate and maintain a distinction between our personal and professional presence on social media where this could result in harmful dual relationships with clients
d. the impact of any dual or multiple relationships will be periodically reviewed in supervision and discussed with clients when appropriate. They may also be discussed with any colleagues or managers in order to enhance the integrity of the work being undertaken.

34. We will not have sexual relationships with or behave sexually towards our clients, supervisees or trainees.

35. We will not exploit or abuse our clients in any way: financially, emotionally, physically, sexually or spiritually.

36. We will avoid having sexual relationships with or behaving sexually towards people whom we know to be close to our clients in order to avoid undermining our clients' trust in us or damaging the therapeutic relationship.

37. We will avoid continuing or resuming any relationships with former clients that could harm the client or damage any benefits from the therapeutic work undertaken. We recognise that conflicts of interest and issues of power or dependence may continue after our working relationship with a client, supervisee or trainee has formally ended. Therefore:

a. we will exercise caution before entering into personal or business relationships with former clients
b. we will avoid sexual or intimate relationships with former clients or people close to them. Exceptionally, such a relationship will only be permissible following careful consideration in supervision and, whenever possible, following discussion with experienced colleagues or others concerned about the integrity of the counselling professions, when:

enough time has elapsed or the circumstances of the people concerned have sufficiently changed to establish a distinction between the former and proposed new relationship

any therapeutic dynamics from the former relationship have been sufficiently resolved to enable beginning a different type of relationship. (This may not be possible with some clients or inappropriate to some therapeutic ways of working.)

an equivalent service to the one provided by the practitioner is available to the former client, should this be wanted in future

the practitioner has taken demonstrable care in ensuring that the new relationship has integrity and is not exploitative

c. We will be professionally accountable if the relationship becomes detrimental to the former client or damages the standing of the profession

38. We will inform clients about any fixed limits to the duration or number of sessions as part of the contracting process.

39. We will endeavour to inform clients well in advance of approaching endings and be sensitive to our client's expectations and concerns when we are approaching the end of our work together.

40. We will inform clients in advance of any planned breaks in working together, for example, holidays or medical treatments, and give as much notice as possible.

41. Any unplanned breaks due to illness or other causes will be managed in ways to minimise inconveniencing clients and, for extended breaks, may include offering to put clients in touch with other practitioners.

42. In the event of death or illness of sufficient severity to prevent the practitioner communicating directly with clients, we will have appointed someone to communicate with clients and support them in making alternative arrangements where this is desired. The person undertaking this work will be bound by the confidentiality agreed between the practitioner and client, and will usually be a trusted colleague, a specially appointed trustee or a supervisor.

50. We will take responsibility for how we offer our clients opportunities to work towards their desired outcomes and the safety of the services we provide or have responsibility for overseeing.

51. We will discuss with clients how best to work towards their desired outcomes and any known risks involved in the work.

52. We will ensure candour by being open and honest about anything going wrong and promptly inform our clients of anything in our work that places clients at risk of harm, or has caused them harm, whether or not the client(s) affected are aware of what has occurred by:

a. taking immediate action to prevent or limit any harm
b. repairing any harm caused, so far as possible
c. offering an apology when this is appropriate
d. notifying and discussing with our supervisor and/or manager what has occurred
e. investigating and take action to avoid whatever has gone wrong being repeated

53. We will consider carefully in supervision how we work with clients - see 60-73.

54. We will monitor how clients experience our work together and the effects of the work with them in ways appropriate to the type of service being offered.

55. We will protect the confidentiality and privacy of clients by:

a. actively protecting information about clients from unauthorised access or disclosure
b. informing clients about how the use of personal data and information that they share with us will be used and who is within the circle of confidentiality, particularly with access to personally identifiable information
c. requiring that all recipients of personally identifiable information have agreed to treat such information as confidential in accordance with any legal requirements and what has been agreed with the client at the time of disclosure
d. informing clients about any reasonably foreseeable limitations of privacy or confidentiality in advance of our work together, for example, communications to ensure or enhance the quality of work in supervision or training, to protect a client or others from serious harm including safeguarding commitments, and when legally required or authorised to disclose
e. taking care that all contractual requirements concerning the management and communication of client information are mutually compatible
f. ensuring that disclosure of personally identifiable information about clients is authorised by client consent or that there is a legally and ethically recognised justification
g. using thoroughly anonymised information about clients where this provides a practical alternative to sharing identifiable information

56. Professional relationships will be conducted in a spirit of mutual respect. We will endeavour to build good working relationships and systems of communication that enhance services to clients.

57. Practitioners will treat colleagues fairly and foster their capability and equality of opportunity.

58. Practitioners will not undermine any colleague's relationship with clients by making unjustifiable or ill-judged comments.

59. All communications between colleagues about clients should be on a professional basis and thus purposeful, respectful and consistent with the management of confidences agreed with clients.

60. Supervision is essential to how practitioners sustain good practice throughout their working life. Supervision provides practitioners with regular and ongoing opportunities to reflect in depth about all aspects of their practice in order to work as effectively, safely and ethically as possible. Supervision also sustains the personal resourcefulness required to undertake the work.

61. Good supervision is much more than case management. It includes working in depth on the relationship between practitioner and client in order to work towards desired outcomes and positive effects. This requires adequate levels of privacy, safety and containment for the supervisee to undertake this work. Therefore a substantial part or preferably all of supervision needs to be independent of line management.

62. Supervision requires additional skills and knowledge to those used for providing services directly to clients. Therefore supervisors require adequate levels of expertise acquired through training and/or experience. Supervisors will also ensure that they work with appropriate professional support and their own supervision.

63. All supervisors will model high levels of good practice for the work they supervise, particularly with regard to expected levels of competence and professionalism, relationship building, the management of personal boundaries, any dual relationships, conflicts of interest and avoiding exploitation.

64. All communications concerning clients made in the context of supervision will be consistent with confidentiality agreements with the clients concerned and compatible with any applicable agency policy.

65. Careful consideration will be given to the undertaking of key responsibilities for clients and how these responsibilities are allocated between the supervisor, supervisee and any line manager or others with responsibilities for the service provided. Consideration needs to be given to how any of these arrangements and responsibilities will be communicated to clients in ways that are supportive of and appropriate to the work being undertaken. These arrangements will usually be reviewed at least once a year, or more frequently if required.

66. Trainee supervision will require the supervisor to collaborate with training and placement providers in order to ensure that the trainee's work with clients satisfies professional standards. The arrangements for collaboration will usually be agreed and discussed with the trainee in advance of working with clients.

67. When supervising qualified and/or experienced practitioners, the weight of responsibility for ensuring that the supervisee's work meets professional standards will primarily rest with the supervisee.

68. Supervisors and supervisees will periodically consider how responsibility for work with clients is implemented in practice and how any difficulties or concerns are being addressed.

69. The application of this Ethical Framework to the work with clients will be discussed in supervision regularly and not less than once a year.

70. Supervisors will conscientiously consider the application of the law concerning supervision to their role and responsibilities.

71. Supervisors will keep accurate records of key points discussed in supervision.

72. Supervisees have a responsibility to be open and honest in supervision and to draw attention to any significant difficulties or challenges that they may be facing in their work with clients. Supervisors are responsible for providing opportunities for their supervisees to discuss any of their practice-related difficulties without blame or unjustified criticism and, when appropriate, to support their supervisees in taking positive actions to resolve difficulties.

73. Supervision is recommended to anyone working in roles that require regularly giving or receiving emotionally challenging communications, or engaging in relationally complex and challenging roles.

81. Trainees working with each other will:

a. relate respectfully to others and endeavour to support each others' learning
b. follow good ethical practice when working with each other, for example when practising skills or in personal development

82. In the interests of openness and honesty with clients:

a. trainees on a practitioner-qualifying course working with clients will inform clients (or ensure that clients have been informed) that they are trainees
b. trainees who are undertaking post-qualification CPD or further training will be guided by any applicable training requirements when using their professional and ethical judgement about whether to inform clients that they are in training

83. All trainees will:

a. seek their clients' permission to use any information from work with them for training purposes, for example, in presentations, case studies or as assessed practice. Alternatively, any report of work undertaken will be so thoroughly anonymised that the identity of the person concerned cannot be identified by any means reasonably likely to be used. Consent is required if anonymity cannot be assured or when required by the training provider's instructions or regulations.
b. ensure that they deliver services that satisfy the minimum professional standards when working as practitioners with members of the public. This standard may be achieved with the assistance of appropriate professional support.
c. collaborate with their trainers, placement providers, supervisors and other professional advisers to provide services to their clients that satisfy professional standards by being undertaken with reasonable care and skill
d. be watchful for any incompatibilities between contractual requirements that have implications for work with clients, for example, between agreements with clients, training providers and placements, and seek appropriate support in order to ensure that all contractual requirements are compatible
e. be open and honest with trainers, placement providers and supervisors about all issues relevant to their selection, training, supervision and professional practice

91. We will take responsibility for our own wellbeing as essential to sustaining good practice with our clients by:

a. taking precautions to protect our own physical safety
b. monitoring and maintaining our own psychological and physical health, particularly that we are sufficiently resilient and resourceful to undertake our work in ways that satisfy professional standards
c. seeking professional support and services as the need arises
d. keeping a healthy balance between our work and other aspects of life

92. We recognise that professional and ethical issues, problems and dilemmas will arise from time to time and are an unavoidable part of our practice.

93. We will use our supervision and any other available professional resources to support and challenge how we respond to such situations. We will give careful consideration to the best approaches to ethical problem-solving.

94. We will take responsibility for considering how best to act in such situations and will be ready to explain why we decided to respond in the way we did.

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BACP Ethical Framework for the Counselling Professions

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All BACP members have to work in accordance with the Ethical Framework. It helps you provide your clients with a secure base for your work together.

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All the events are represented on the interactive timeline and can be visualized. You can review all the cause-and-effect relations of timeline

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The future of psychedelic-assisted psychotherapy | Rick Doblin

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Psychologist - Studies the theory of how the mind works, including emotions, cognition, behaviour and memory. If working with clients, they tend to specialise and go onto further study.
Psychiatrist - A medically trained doctor who specialises in the diagnosis, management and prevention of mental health issues. They diagnose clients and prescribe treatments.
Psychotherapist/Counsellor - Uses talking therapies to help clients overcome and manage mental/behavioural issues in order to live a more full and satisfying life.

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The Psychedelic Experience - Mind Field S2 (Ep 2)

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The government made psychedelic research illegal in retaliation to protests against the War.