We need to talk about GP appointments...

Hot on the heels of the mental health debate in the Welsh Assembly Government last week, Health & Social Services Minister Mark Drakeford took the opportunity yesterday to announce an additional £650,000 of funding for psychological therapies in Wales. How that will pan out on the ground to help out with waiting lists of up to 6 months in some areas has yet to be seen, but it is, nevertheless, a good news story.…

However, another news report, with a somewhat bleaker outlook, also caught my attention this week. Dr Paul Myers, chair of the Royal College of GPs, said that “the GP profession in Wales is at risk of crumbling in just five years unless greater investment is put into the system….” He added that issues with workforce and recruitment, as well as increasing workloads for GPs, meant morale was at rock bottom and some practices were facing closure.

Dr Myers warns that unless there is an increase in NHS funding for the profession from 7.8% to 11%, general practice in Wales could fall apart in a matter of years. This is not the first news story to highlight the crisis in the Welsh GP service… ITV reported in April this year that many GPs are reaching retirement age, and recruitment is proving challenging particularly in rural areas of Wales. Retired GP Roger Burns from Pembrokeshire drew attention to some of the issues, including this most recent story, on NHS Reality.

When people experiencing mental distress for the first time (or those close to them) contact us at our Information Service, one of the first options we suggest is that they make an appointment to see their GP. But these days that process might in itself provide a barrier to recovery.

When I have needed to see a GP in the last twelve months I have rung and been told that there is a two week wait. Last week a PAVO colleague was informed that it would take a month to see the GP of her choice! So, when I know I really need to see a GP quickly I follow a regular routine, especially if it is a Friday or Monday. I make sure I am up and by the phone at 8.30am when the surgery opens. And then I start ringing. Usually the line is engaged. Everyone else is probably doing the same! We are, in effect, competing to win the very few appointments – usually cancellations – that might still be available on that day. I might press redial fifty times before I eventually get through…but whether I will be lucky enough to get an appointment that day is another matter…

I can’t help wondering to myself… but what if the other people who are trying to get through to the surgery switchboard have a really serious problem they need to talk to their GP about… maybe they are older… or have a young child… who decides who should be seen first? No one! It is a complete lottery!

When we do get an appointment there is more waiting involved… This business of looking after our health and wellbeing is truly a waiting game.  Last time I sat for 45 minutes after the time my appointment was scheduled, in a GP surgery absolutely bursting at the seams, before I saw a GP. And once I’m in there for my snatched five minute consulation I almost feel guilty for taking time out of the busy GP’s life… S/he has to see about 59 other patients that day after all…

And if you are emotionally distressed, where will just five minutes with a GP get you? Especially if you are told that the waiting time for psychological therapies could be many, many months?

So, really I’m not at all surprised to read Dr Myers’ comments… or to note that Dr Charlotte Jones, chair of the British Medical Association’s Welsh General Practitioners Committee, warned last month that general practice in Wales was in “intensive care”.

According to the Royal College of GPs - due to the sheer volume of GP workloads, in this year alone, patients will have to wait longer than a week to see their GP on at least 27 million occasions.

In another online article this week, it was reported that nurses at the Royal College of Nurses’ annual conference suggested that: "patients should be charged up to £10 a time to see their GP to deter "time-wasters" and those with minor symptoms". (On the same webpage is a link to a video called “Self diagnose illness with new apps”…..)

Would you be willing to pay £10 to see a GP if it cut down on appointment waiting times?

There is a petition – calling to save general practice Wales – on the Royal College of GPs’ website here.

Mental Health (Wales) Measure – how is it measuring up?

Late on Tuesday afternoon this week I tuned in to the live debate on Improving mental health and wellbeing in the Welsh Assembly’s debating chamber in the Senedd. (You can watch archive video of the debate here 2hr 52min in or read the plenary notes here, at 16.21). In the debate, Assembly Minister Janet Finch-Saunders commented:

Today’s debate on mental health looks at an issue that can affect any member of our society, from the very wealthy to those living in poverty, male or female, young or old. Our mental health is not static and it certainly does not discriminate. Those who have been well all of their lives can suddenly find that a turn of events or a change in circumstances can affect their own mental health wellbeing. It can show itself in a variety of manners, from depression or mild anxiety to post-traumatic stress disorder and/or severe psychotic problems. Minister, I have to say that probably one of the hardest jobs for me as an Assembly Member has been when someone has presented and I find them, quite literally, crying out for help, for support, and yet feeling, you know, that nothing can be done.

Health & Social Services Minister Mark Drakeford introduced the motion, which proposed that the National Assembly for Wales notes Welsh Government action to improve mental health and wellbeing in Wales. He said:

Here in Wales……. change is happening, and it is making a significant and positive difference for those whose lives are affected by mental health problems. The basis for all this is, of course, the Mental Health (Wales) Measure 2010, the Assembly’s groundbreaking legislation.

The Mental Health Measure, which became law in 2010, introduced legislation around mental health for people in Wales which is quite different to that in the rest of the UK. We highlighted 10 interesting facts about the Mental Health Measure in October 2012 and provided further information, including videos, on our website here.

But is it working?

That question is being asked both formally and informally in Powys (and all around Wales) right now. People who have been in contact with services, those close to them, and those providing the services, are being surveyed, are meeting in focus groups, and sometimes contacting politicians such as Assembly Minister Kirsty Williams to represent their views in the Senedd debates (including this one, see 17.09 in, for an update on Brecon).

We thought we would write about elements of this review process on the blog over the coming months to highlight some of the issues that are coming to the fore.

Earlier this year, in April, the Welsh Government published the findings of a review of progress made so far against the aims of the Measure as part of an early Scoping Study carried out by Opinion Research Services (conducting Research to support the Duty to review the Mental Health (Wales) Measure 2010). With regard to Care and Treatment Plans (for people receiving secondary mental health services such as seeing a psychiatrist or community psychiatric nurse) the report highlighted that: Many consultees argued that the Measure persists with a medical model of care which in practice is neither recovery nor outcome focused and which takes little account of the social care needs of service users. To make the recovery process work as embodied in the Measure, there is a need to take positive risks with service users by allowing them to lead the process. However, this requires a complete change of culture.

The Royal College of Psychiatrists had already conducted an independent review looking at the impact of the Measure from the psychiatrists’ point of view, publishing the results of their findings in late 2013. 48.5% of respondents (out of 121 – a 20% response rate for the survey overall) said they noticed a negative change in the care given to patients since the Measure was implemented. They pointed out issues including: increased workload but reduced patient care, potential risks of patients slipping through the net, early discharge of patients, and concerns regarding legal implications of increased bureaucracy.

My colleague Freda Lacey has recently been involved in some local focus group sessions in Newtown and Brecon where people have looked at their experience of changes in provision of mental health services since the Measure became law. This research is again being carried out by Opinion Research Services with Freda’s support and a short report on the focus groups will be available soon.

In the meantime, have you been in contact with mental health services? Perhaps you have attended a GP surgery and tried to access counselling via your Local Primary Mental Health Support Services (LPMHSS)? Or you may have been referred to see a Community Psychiatric Nurse who works as part of a Community Mental Health Team? Do you understand what the Measure means to you, and have you any feedback about the way it’s working? Let us know what you think by commenting below.

Play and mental health: mucky is good!

My colleague, Yvonne Owen-Newns, is the Children & Young People’s Facilitator at PAVO.  As part of her role she focuses on play, lucky person! I am seriously envious! Is she out playing Please Mr Crocodile, Freeze Tag or What’s the time Mr Wolf? while I’m busy emailing everyone the June issue of our mental health ebulletin….? I’m going to ask Laura if we can have play breaks in our team!

Anyway, Yvonne actually takes her work with play very seriously. She looks at the importance of play to children’s health and wellbeing, and works closely with a myriad of other organisations to ensure that the children of Powys have genuine opportunities to play. She recently went to Wrexham to check out some of the amazing children’s playgrounds they have developed there… they are more like the wild dens out in the woods that I recall playing in with such freedom and enthusiasm as a child… Lucky children of Wrexham!

Yvonne is helping to organise a conference on play on 25 June in Llanelwedd at the Royal Welsh Showground, and reading about the content of the day made me think more about the importance of play to children’s emotional wellbeing.

In 2012 Play Wales produced a report outlining the relevance of play to both physical and emotional wellbeing, with recommendations for the role of public health professionals in promoting play opportunities.

How playing contributes to children’s emotional well-being:

• Creating and encountering risky or uncertain play opportunities develops children’s resilience and adaptability – and can contribute to their confidence and self-esteem.
• Socialising with their friends on their own terms gives children opportunities to build emotional resilience, to have fun and to relax.
• Fantasy play allows for imagination and creativity, but it can also be a way of children making sense of and ‘working through’ difficult and distressing aspects of their lives. 

There is an increasing realisation of the importance of outdoor and what we might now think of as “risky” play…. How many parents would allow their youngsters to do as I did as a child – head off on my bike with my mates into a nearby wild woodland area with a large lake and build tree dens unsupervised? Instead young people sit in front of their electronic devices for hours on end… In the recently promoted Children’s Outdoor Charter of Rights there is a section on risk-taking which states: "Children have the right to learn from challenge, to experience failure as learning and to become confident and adventurous explorers of the environment. Safety concerns therefore need to be balanced with the child’s need to experiment and grow."

Journalist Rob Parr asked why fun is not taken more seriously in The importance of play in a recent Times Educational Supplement article. His piece outlines studies around play which “found that play-deprived children manifest responses on a scale ranging from unhappiness to aggression.” Several studies show clear links to criminality and reduced creativity, and Research Professor Peter Gray from Boston in the United States states: “what I think is the most dramatic effect of the play deficit: the increase in childhood depression and anxiety, and decrease in self-control…over the past half-century.”

And it seems play is, indeed, not just about having fun… it is a serious business, it’s about learning the skills for life, as outlined, again by Peter Gray, on Psychology Today in 2009. “A lively outdoor group game may be physical play, language play, exploratory play, constructive play, social play, and fantasy play all at once. Play, in all its forms combined, works to build us into fully functioning, effective human beings.” And children “playing strive to perform well, because performing well is an intrinsic goal of play, but they know that if they fail there will be no serious, real-world consequences, so they feel free to experiment, to take risks in ways that are crucial to learning."

                                                                                                                               

So… what plans are afoot in Powys to further develop play opportunities? Powys County Council has a statutory duty to “provide sufficient play opportunities” and to promote them. There is already a Powys Play Partnership which “aims to become a wide network of organisations and agencies (from statutory and voluntary sectors) who work with the communities in Powys and have an interest in developing more child led play for more families.” The partnership developed the Powys Play Pledge in 2013.

This latest conference will look at how agencies and groups can incorporate play into their services “using simple techniques and methods which will benefit the residents and visitors of Powys”. It will also address the subject of ‘Risk in Play’ – the myths, the issues, the barriers and the solutions.

Can you contribute and make a difference to play opportunities in Powys? And what do you think about the importance of play to children and young people’s emotional wellbeing?

Wednesday 25 June Play Conference: Managing Risk Playing More

Oh, and there's a dog...

Sandra Ward, Information and Advice Manager for Age Cymru Powys, talks to us about older people in rural communities and her vision for help and support that could make a real difference.

Tell us about your day job

I have been an adviser for 30 years – that makes me feel very old.

It really is a strange way of earning one’s living, but it can be both rewarding and interesting. I never know what the day will bring – it can range from the sublime to the downright heartbreaking. From advising how to deal with a bee swarm lodged in a chimney, to supporting a lady of 92 coping with losing her lifelong partner and for the first time having to deal with banks, benefits and all the paperwork which follows a death.

I know we all suffer the distress of easing information from, and giving help to, those who are in a ‘bad’ place. But in the midst of these problems are lighter moments. One of my longest days was when I was with the Citizens Advice Bureau. I was helping a young family who were homeless. It was a Friday, especially relevant because one is aware that the problem has to be solved that day – nothing will be open over the weekend. Panic time then! I had spent most of the day finding this young couple somewhere to stay, and this was before the 3 young children came out of school. But at 4pm I was triumphantly standing at the door of the Advice Centre ready to speed them on their way to a booked and funded bed and breakfast. The young father suddenly turned and said; “Oh, and there’s the dog!” (An Alsatian, of course!) I often mutter to myself in times of stress - when I need a giggle - ‘and there’s the dog’!

Powys is a rural county, what does this mean for older people?

As Manager of Age Cymru Powys (formerly Age Concern) I see a great many people with problems which are aggravated by the fact that they live in a rural location. For my clients the additional rural problems are the following: difficulties in accessing help and advice; support services are either stretched by distance or non existent; lack of transport – whether that is limited public transport or simply that due to age and/or disability they have lost the use of their own transport. This of course, affects access to health services especially in Mid Wales where we are often sent to Telford for hospital appointments. All these limitations can cause acute loneliness – something the majority of the people I speak to suffer from. My job in Powys is almost completely different to that of an Information and Advice worker in an urban area where supporting services are near at hand.

Powys (my patch) is the 9th most rural county in the whole of the United Kingdom and the least most populated in Wales. The average population in Wales is 147 people per square kilometre, in Powys it is 26. Also we are ¼ of the area of Wales, so some of my outreach service advisers can travel for 1½ hours just to get to their destination. So you see I really do know about rural poverty.

Is there anything causing real concern to older people in Powys at the moment?

At present we are finding that the Government Welfare Reforms are causing us a great deal of work. Don’t get me wrong, I agree that a fit and able person of working age should be employed. It is only when knowing that one is valued and worthwhile that you gain self respect and self esteem. However, if you are 50+ and have health problems – maybe a stroke or an accident at work; you are actually less likely to be able to work. Possibly the job you trained for and have always done is now physically beyond you, so your whole life has to change. This is fine if you are fit, alert and mentally able to cope with complete change, but if you are depressed and unwell to suddenly find yourself in a minefield of forms and interviews it becomes impossible to find the impetus to navigate onwards. My colleagues and I help them do this and it can be both difficult and very, very sad. People are angry because they can’t work at their chosen trade, depressed because their life has changed for the worse and very frustrated that the Welfare State, far from helping them, seems intent only on making them slot into a ‘fit for work’ category.

I had a client, a gentleman of 64 who had previously worked on the land; he had had a stroke and was quite disabled. However, he was found by the Employment and Support Allowance Team to be fit to do office work. This chap was unable to use one side of his body and was incontinent. I explained the ruling and possible options for him. He sat quietly in my office, then said; “I would rather be dead than sit in an office smelling of urine.” This man had worked constantly for 35 years and had never expected to rely on state benefits. Not the type of unemployed scrounger that some of the politicians and the popular media portray. I am on a few national committees, not because I have the time but because people like that man are unable to verbalise their frustrations – but I try to make their feelings known and understood.

What other challenges do you face in Powys?

The challenges of communication both in reaching those who are vulnerable and for older people to participate in social activities are vast. Public transport is very limited, many of the bus routes are weekly services or limited to one or two buses a day – a large number of villages are not visited at all. We have recently lost even more of these routes. Over ½ Powys households are classified as being in area 8, ranked the worst 10% in Wales for access to services on foot or by bus.

Interestingly we also find that language causes a barrier. We run a bi-lingual service but find that the majority of our work on the Welsh border is requested in English. As we ‘go west’ across the county it becomes more predominately Welsh. Because my main office is in Newtown some people consider our service ‘English’ and hesitate as to whether they would find help there. In fact some of my ‘main language Welsh’ clients are additionally vulnerable because they have scant knowledge of the help they could access.

I have over the last 5 years piloted and run an elder abuse project for Powys County Council. I chose primarily to visit Lunch Clubs because these are the older people who are just coping but needing some support and therefore beginning to be at risk. It involves a positive and upbeat talk; firstly about older people’s rights – such things as ‘You have a right to be wrong!’ So many elderly people keep silent, terrified that if they make a mistake they will be ‘put in a home’. We fight to give them control over their lives, without making the judgement of ‘what is best for them’. We then go on to discuss scams and abuse, in an open and safe environment. Sadly 60% of the 300 people I spoke to had been a victim of scams or abuse. If people are living in isolated rural areas they are far more likely to be at risk of unreported abuse. There is a desperate need for our advice service to reach these isolated and vulnerable people.

How would you like to be able to help older people in Powys more?

I started thinking about the problem from the bottom up, so to speak! I am involved in rural church life and have been for my whole life. As a child our church was the hub of our rural community and many problems were supported therein. Now I believe this supporting network has changed – the age range in our communities is unbalanced. Despite all our best efforts to attract the young, many of our congregations are made up of older people. A few of the more successful churches use their buildings completely and offer crèches, welfare advice and community projects like cafes.

I had this in mind when I thought about my new project. As advice workers we need to be out there helping the lonely and vulnerable but I cannot sanction the expense for my advisers travelling 80 miles for a home visit, even if it is essential. So I thought that if I had a volunteer in each community and a paid adviser in a main office, whether it be Newtown, Llandod or Brecon then the volunteer could listen to the problem and phone for advice. The Bishop of Bangor informed me that the Church in Wales is keen for their buildings to be fully utilised - so churches, and maybe chapels, community centres and schools could be used at set times every week. My plan is that this would form a network of people to be a core community and therefore support their population who were at risk or in need. I’m just at the stage of trying to get funding for this but hopefully it could plug a little hole in the dyke!

What I see at present is that many people living in rural areas are being subjected to increasing stress and anguish as a direct result of decisions made in Westminster and elsewhere. It is necessary that we speak out – without prejudice – to inform those whose upbringing and life style leave them ignorant of the challenges of rural Wales. Reaching those who need help remains my priority and frustrating though it often is, I feel very privileged and honoured to be in a position to attempt this.

If you would like to discuss this idea with Sandra or offer her some support, you can get in touch with her on 01686 623707 or sandra@acpowys.org.uk or leave a comment below.

Powys Mental Health Alliance Open Day 2014

Yesterday my colleague Freda and I went along to the latest Powys Mental Health Alliance Open Day at The Commodore Hotel in Llandrindod Wells. These days are a great opportunity to find out more about what is happening in the county around mental health, and to meet up with other members and people representing organisations to chat, catch up and have... as it happens... fun! The big yellow inflatable football in the photograph below is a bit of a clue...

L - R, top row: Debra Douglas-Matthews (PMHA trustee), Philip Bowen (High Sheriff of Powys),
Bryan Douglas-Matthews (PMHA chair)
middle row: Christine Field (PMHA trustee),  Kelvin Mills (PMHA trustee), Carla Rosenthal (PMHA magazine editor)
bottom row: Bill Fawcett (PMHA Vice Chair), Michelle Hart (Stretch & Smile)

Surprise guest this time round was Philip Bowen, the High Sheriff of Powys. "The Office of High Sheriff is an independent non-political Royal appointment for a single year". Philip has many hats it seems, as he is also Artistic Director of The Willow Globe - a scaled down, living willow theatre, based on The Globe Theatre in London. Philip enthusiastically opened the day with, appropriately enough, a reference to some of the distressed heroes of Shakespeare's plays, including Prospero and Pericles. By the end of the drama they are able to say - "this is who I am.... this is my story." Through the storytelling process they are healed.

Eddie Evans, the Regional Welfare Officer for Combat Stress, the veterans' mental health charity, kicked off as first speaker of the day. He had served in the army for 26 years, and now works with Community Psychiatric Nurses and Mental Health Practitioners to provide support to ex-servicemen and women in the community.

Eddie spoke about Post Traumatic Stress Disorder (PTSD) - "a normal reaction to an abnormal situation". Personnel often go back to their families after being in a war zone and try and start up again as if nothing has happened... but problems can quickly escalate if people need help. "It is as if the wheels fall off before some people seek help... there are failed marriages, lost jobs..." Eddie is the first point of contact for people as there "is a bond of history". Some veterans can receive support in the community, including practical support if there are money issues; others, who may be more severely distressed, enter one of three Combat Stress treatment centres - the one serving Wales is in Newport, Shropshire. "Some veterans smile for the first time as they are amongst other veterans."

Freda catches up with Eddie Evans in the coffee break

Eddie's obvious understanding and empathy for struggling veterans was picked up by several people in the audience, who responded by describing moving experiences relating to themselves and family members. "You could not believe some of the sights that they see..."
"My son went away for a week (with Combat Stress) and the difference was so remarkable that you wouldn't think it was the same person!"
"People don't realise that veterans suffer from mental health problems in a big way."

The coffee break was followed by a brilliant session of seated exercises with Michelle Hart from Stretch & Smile. Nearly everyone joined in, including the High Sheriff of Powys and Freda! 

L - R: Carla Rosenthal, Philip Bowen, Michelle Hart & two others stretching!

These were just the warm-up exercises.... but then the large inflatable balls were rolled out and the real fun began... 

Chris Coe - Am I really as tough as old boots?

How to follow that...? Well, what better choice than Chris Coe of the Farming Community Network (previously Farming Crisis Network).

Chris had been a Rural Officer with the United Reform Church when an opportunity arose for an additional part-time post - this time as Regional Director for FCN based in Llandrindod Wells. Chris explained that the charity's main role was to "walk with people" - to be there, to listen, to respond - as a friend. He can go with farmers to court, to the bank, to a doctor... shopping... even organise to have a field ploughed if that is what is needed when someone is too distressed to do the work themselves. The service is free and confidential. The hardest part is encouraging people to ask for help in the first place.

Chris works with a large team of volunteers covering Powys and SW Wales... and if the two case studies he gave us are anything to go by the work is very much needed in the county. He said "45% of the people helped suffer some form of mental illness caused through the stress and hardship of producing the food we all depend on." The farming community is currently bracing itself for changes in the Single Farm Payment from the government which so many depend on to stay afloat.

After a delicious lunch Inspector Brian Jones of Dyfed-Powys Police stepped up to take the microphone. He is stationed in Brecon and works as a Partnership Inspector - one of his key responsibilities being mental health. The two main areas of discussion which developed around this session focused on the Section 136 detentions (when people are taken to a place of safety and possibly assessed by mental health professionals before a decision is made about next steps) and police training.

Many of those in the audience were keen to relate their own experiences of contact with police officers whilst distressed, some of them quite negative, and Brian listened carefully to them all.

Brian explained that:

• Sometimes people will be taken into custody when they shouldn't be.
• Sometimes people don't know who to call when a crisis/incident develops so they call the police.
• New officers (recruited over the past 2 years and ongoing) have to spend three days in Bronllys Hospital as part of their training.
• A new training programme is being developed, in partnership with other organisations including Powys Association of Voluntary Organisations (PAVO), which will be rolled out to all officers. Individuals, including those in contact with mental health services and those close to them, will be involved in this training. Mental Health First Aid sessions are also likely to be made available.
• He is trying to bring about change and influence to the police by listening to people's experiences (which is why today was so valuable to him).

There followed a much longer discussion, including topics such as anti-social behaviour, multi-agency problem solving, mental health advocates and hate crime... if only we had the space and time here to relate it all! At the end of a really interesting session Brian rounded up by saying: "Give the officers a chance. Approach them. Speak to them. When we are called out we will say - the next time we come here, how would you like us to treat you? Tell us and the details will be linked to your address. We want to do the best we can."

Other mental health organisations were present on the day, and Freda and I enjoyed meeting up with colleagues at The Alzheimer's Society:

Kate Llewellyn (Advocate) and Pat Griffiths (Dementia Support Worker)

Pat reminded me about the Memory Cafe which runs every second Friday of the month at the Methodist Church in Newtown.

Here at Powys Mental Health Information Service we often signpost people to Journeys and the C.A.L.L. helpline, so it was great to meet everyone at their stands.

Lorraine Jones and Jackie Faichney of C.A.L.L. Helpline 

Gareth Childs, Journeys

Finally, I'll sign off with this photo of Freda joining Pat and Kate of The Alzheimer's Society for the Stretch & Smile session... The smiles on their faces say it all!

We look forward to the next PMHA Open Day. If you were there, tell us what you thought. Do you have suggestions about speakers or activities for future open days? Did you try out the Listening Table? Or listen to Diane Milberry's talk? We'd love to know, as we had to shoot off back to the office at that point...

Exploring Mental Health and Trauma: Books To Get Us Thinking ....

Guest Blog by Jane Cooke.

There has been a focus on trauma-oriented work and ‘treatment’ in recent Powys conferences.  You can watch Jacqui Dillon at the Powys Stronger in Partnership conference last year here and you can watch Sami Timimi at the Finding Meaning in Psychosis conference in March 2014 here.

One of my roles in life (when I’m not working within PAVO’s mental health team) is as a counsellor/psychotherapist. I have a trauma-oriented approach which has been reinforced by listening to these speakers and by reading around the subject.

A trauma-oriented approach, as advocated by Sami Timimi, is a gentle way of beginning work that enables a person to feel safe and able to gradually build up a personal sense of control over their own boundaries and in time over responses to events or reminders that can lead to upsetting and overwhelming reactions. Even if a person doesn’t identify trauma as being relevant to them and why they come for therapy, this approach is empowering and helpful anyway. (It is not about forcefully inducing ‘catharsis’, re-living the situation, ‘facing up to it’ or any other similar techniques which can be re-traumatising or even abusive in themselves.)

Sami Timimi is a psychiatrist and a founding member of recently established Council for Evidence-Based Psychiatry.  He believes that working in a trauma-oriented way makes sense for most people who come into contact with mental health services. Much more sense than identifying ‘pathology’, symptoms and ascribing a diagnosis; all of which generally ignore the story, the experience of the person, how it is that they are who they are.

There are two writers who I have found very helpful and their work complements each other. Both Judith Herman and Peter Levine are concerned that people (clients, patients, service users, survivors) gain/regain their own sense of personal power and agency as they recover from their trauma/s.

Peter Levine has written a number of books about trauma. One of his books “Healing Trauma” is a slim self-help book with a CD covering a programme of exercises that anyone can follow to help overcome the neurological ‘holding’ of trauma. It is, he says “for restoring the wisdom of your body”.  He does caution that professional help may still be required. An empowering way of working could be therapist and client working together with the book and exercises, keeping the client in control of the work.

‘Trauma’ is a word we use in everyday speech,  but paradoxically in relation to emotional well-being there is a limited perception that trauma has to relate to major events that are, for example, combat situations, witnessing  extreme violence, being in danger of one’s life or experiencing sexual violence or abuse in childhood or adulthood. However, as Peter Levine says “People, especially children, can be overwhelmed by what we usually think of as common everyday events …The fact is that, over time, a series of seemingly minor mishaps can have a damaging effect on a person. Trauma does not have to stem from a major catastrophe” (his italics).

There is increasing evidence for this. So, for example, bullying, repeatedly not getting your needs for love and positive attention met, feeling fear regularly such as maybe a frightening  walk to school, regular contact with a frightening , threatening teacher or relative; being regularly shamed by powerful people when you are young.  Many things can build up to create a response in the nervous system which then needs to be ‘taught’ to respond to the here and now and to recognise/feel  current sources of support and comfort, including your own capacity  to support and nurture yourself.

Jacqui Dillon (a survivor of childhood sexual abuse) told us how much she had been influenced and empowered by Judith Herman’s book “Trauma and Recovery”. Herman looks at the way in which women’s (and children’s) experiences of violence, fear, captivity (and you can be captive in all senses without the doors being locked) and powerlessness in the domestic and community realm have been seen as variously: natural, bought on by the victim themselves, exaggerated  and overcome-able by normal acts of will. She looks at the way in which their experiences are minimised and belittled.  “Social judgement of chronically traumatized people tends to be extremely harsh” .She also looks at ways of working with people who have experienced trauma. Judith Herman has a framework for recovery from trauma. There has to be in her experience, in sequence (and returned to as often as necessary) Safety, Remembrance and Mourning and Reconnection. This works very well with Peter Levine’s work which in the early stages emphasises ways of achieving an inner sense of safety, and of course actual safety in daily life is essential.

Judith Herman is very clear that therapists need good training and good support, this is work that can be complex and challenging.

There are many books about trauma; I would recommend these two. They are compassionate and well-grounded in research and experience. They are as much for the person recovering from trauma as they are for therapists and other workers.  

Judith Herman’s “Trauma and Recovery provides a radical, community oriented approach to recognising trauma in the lives of women in particular as well as a way of working that can lead to recovery.

Peter Levine’s book is a gentle, practical self-help book (although he does not minimise the need for professional support as well).

Between them they are a very good ‘starter kit’ to this subject whether you are a health professional, or someone who has experienced, is experiencing, trauma – and you could very well, of course, be both.

Trauma and Recovery. Judith Herman.  Pandora  ISBN 978-086358-430-5

Healing Trauma. Peter Levine. Sounds True ISBN 978-1-59179-658-9

Written by Jane Cooke

Member of PAVO Mental Health Team:  jane.cooke@pavo.org.uk

And when not working for PAVO....

Gestalt therapist, ecotherapist  and interpersonal skills trainer.  Jane.cooke@heartfeltwork.co.uk

www.heartfeltwork.co.uk

Crisis cards or a buddy – maybe an app will do?

In North Powys members of the mental health charity Ponthafren Association can apply for a crisis card. Traditionally such a card is used to give someone chance to say how they wish to be treated in a mental health emergency when they may have difficulty in making their wishes known. The card could contain a list of useful organisations that people could contact in a crisis, and also details of someone close to the person who should be contacted to support them through the crisis.

I was interested to know if other organisations are providing cards – we are occasionally asked this question by people emailing or ringing our Information Service, and so set about researching the topic online…

What soon became clear was that most of the pages in my “crisis card” search threw up historical documents. There was much of interest to be read about the original development of the crisis card, such as the fact that: the first card to be used in this country was developed by the UK-based International Self Advocacy Alliance and jointly launched with Survivors Speak Out in 1989.

Articles going back to the nineties, when the initiative was first being developed, included detailed analysis of potential content of crisis cards. Some discussion papers seemed to imply that a paper document the size of a book rather than a simple credit style card might be required, as described in this article in The Psychiatric Bulletin in 1998.

But times have moved on… and my ongoing search then revealed that paper copies of cards are being superseded in some areas of Britain by mobile phone apps providing a similar function. In Cambridgeshire the SUN (Service User Network) has developed and promoted its own crisis card mobile phone app, which was launched with a flash mob event in Cambridge city centre in December 2013.  According to the SUN Network website: "The crisis card mobile phone app provides a one-button-press ‘call for help’, so you can reach out to your support network without having to face a phone call".

The app is free, and whilst it has been developed and designed in Cambridgeshire it is available for use by anyone in the UK.

Kate Brown, physiotherapy lead for inpatient mental health services at Cambridgeshire and Peterborough Foundation Trust, said: “The app is designed to help mental health service users in times of crisis but also as a way of monitoring their mental and physical health. We’ve demonstrated it to our ward staff and the staff have shown it to patients so they can use it after they have been discharged. It’s a new way of people getting help and it’s been welcomed by our staff and service-users.”

And mobile phone apps are not only being used to replace crisis cards but to support people experiencing mental distress in all kinds of situations. The apps are often developed by National Health Service trusts in consultation with people in contact with their services. A brief search highlighted the following readily available apps:

• My Journey – developed by Surrey and Borders Partnership NHS Trust – by staff and people using the Early Intervention in Psychosis Service.
• QDoc – developed by the Black Country Partnership NHS Trust – “to support mental health service users manage their consultations.”
• Buddy – developed by South London & Maudsley NHS Trust - clients “use text messaging to keep a daily diary of what they are doing and how they are feeling, helping to spot and reinforce positive behaviours.”

And the NHS has, on its own website, a new library page dedicated purely to mental health apps, which have “been reviewed by clinicians to ensure that they are safe and trusted.” In a digital world where it can sometimes feel that we are being bombarded by apps we can at least feel somewhat reassured that someone has checked out the app for us in advance, perhaps? (Some of the apps are free, and others have to be paid for).

What do you think about mobile phone apps aimed at supporting people in mental health crisis or emotional distress? Have you tried one? If so, have you found one you like? If you haven’t tried one, would you like to? What about the range of apps available... do they cover approaches that interest you, or are there still gaps in provision? 

Would you rather have a real life buddy, a Buddy app, or both? Let us know what you think in the comments box below.