Unit 1 – Understanding Mental Health Section 1 – The Meaning of Mental health and Mental Ill-health Q1a Define what is meant by 'mental health'. (1.1) Mental health is a part of a person’s whole well-being. It involves how a person feels about themselves and how they perceive others see them. It includes, but is not limited to, their ability to cope with day-to-day life and the emotions involved with this; their ability to make and sustain positive relationships with friends, family and colleagues and their belief in their own ability to achieve their goals. Q1b Define what is meant by 'mental ill health'. (1.1) Mental ill health is when a person experiences a significant change in behaviour or psychological thought patterns. It can affect a person’s ability to function on a day-to-day basis - often making even normal tasks difficult to complete. Mental ill health can manifest in many different ways depending on the type of mental health illness a person is suffering, ranging from mood fluctuation, feelings of hopelessness and lack of motivation to physical symptoms caused by aspects of mental ill health. Q2 Describe the components of mental well-being. (1.2) Mental well-being is made up of lots of different components and includes but is not limited to the following: A sense of calmness and the perception that 'life is on track' - feeling that everything in life is how it should be can have a massive positive impact on a person's well-being. 'If life is good, we are good'. Positive self-esteem and a feeling of worth - if you feel good about yourself and your worth you are more likely to be able to sustain positive relationships with friends, family and colleagues. We draw emotional strength from people around us and positive relationships with others are vital for mental well-being. Good physical health and diet and exercise can result in an increase in endorphins (a feel good chemical within the brain) which have a positive impact on how we feel. The ability to cope with stress and to be resilient and 'bounce back' from disappointment and negative situations - everyday life is full of highs and lows, the resilience to cope with the lows is vital to the mental well-being of a person. An ability to regulate emotion and cope with different emotions is also important to a person's mental well-being - if we allow anger to rise it has a direct impact on our bodies physical symptoms (blood pressure rises which can increase a risk of physical health issues) - if we allow sadness to take over it can lower our mood and lead to depression if not addressed. Q3 Describe the risk factors associated with developing mental health problems. (1.3) The risk factors associated with developing mental health problems are anything which can increase a person's likelihood to develop a mental health problem. Genetic inheritance - having a close blood relative with a mental health disorder can increase a person's risk of developing mental health problems themselves. However, this link would only increase the likelihood of developing the same mental health problem as that close relative. For example if a parent has bi-polar disorder then it is possible their child would be at risk of the same condition. Gender and age - Women are more at risk than men of experiencing depression, anxiety and phobias - a study by Cambridge University in 2016 found women were twice as likely to suffer anxiety than men, and men and women under the age of 35 were more at risk than older people. Lack of access to food, water or shelter - The constant stress of coping without basic environmental resources will wear a person's resilience and ability to cope away. If you are hungry or thirsty you are more likely to experience a change in your behaviour (the term 'hangry' indicates hunger can make a person more prone to anger and less likely to cope with the emotion). Thirst can cause a slowdown in thought process making decision making more risky and problematic. Lack of shelter (homelessness) can cause a deterioration in a person's self-esteem, manifesting a feeling of worthlessness and puts them at an increase in possible risk taking. Negative experiences at school or in the workplace - bullying in any form can have a major impact on a person's ability to cope with stress and can impact on a person's ability to change their pattern of thinking/behaving. Research in the past has shown that if you're bullied as a child or teenager, you might be twice as likely to use mental health services as an adult. Substance abuse - the abuse of substances can often hide an underlying mental health problem. Using alcohol to 'self-medicate' anxiety when in a social situation to feel more at ease can lead to an increase in risky behaviour and development of a lower mood. A study involving nearly 2,000 German adolescents and young adults found that new cannabis use almost doubled the risk of psychotic symptoms in the years after use. Q4 Identify examples of mental health problems. Within your answer, you should state the name of each mental health problem and provide a brief description of each example you include in your answer. (1.4) Anxiety - this is a constant worry about aspects of everyday life. It can affect sleep hygiene - usually a lack of sleep; cause restlessness (the need to be moving constantly, often fiddling with fingers or twitching of legs).and it can cause physical symptoms such as stomach upset, sweating, elevated heart rate and headaches. Depression - this is low mood often accompanied with feelings of despair, worthlessness, exhaustion and a lack of motivation. It can affect appetite, self-esteem, sleep hygiene, self-care. It can be mild or severe and can interfere with daily activities. Personality disorders - There are several different types of personality disorder. The most common type is a borderline personality disorder - a person suffering with this tends to have disturbed ways of thinking, impulsive behaviour and problems controlling their emotions. They may have intense but unstable relationships and worry about abandonment. A person with an antisocial personality disorder can become easily frustrated and have difficulty controlling their anger. They are often aggressive and can be violent and will often blame others for their problems. Bi-polar disorder affects your mood - swinging from one extreme to the other often with each mood lasting for several months. A person with bi-polar will experience highs or periods of mania - often being overactive and impulsive; or lows and depression - feeling lethargic and worthless. Some people with bi-polar will say they have never experienced a 'normal mood'. Section 2 – How mental health care has changed over time Q5 Describe how mental health care has changed with regard to: (2.1) a) Historical approaches to care Historically, mental health care involved the segregation of people in large asylums which provided no organised systematic care as they all had individual rules, regulations, policies and treatment practices. Common treatments were the use of sedative drugs and baths for calming, although some asylums did provide extensive grounds and greenery and fresh air for patients benefit. The asylums were often used for long term residential care for patients with a wide and varied range of conditions which included learning disabilities, behaviours such as promiscuity, physical problems such as epilepsy and even for having an illegitimate child. In the early 20th Century large rural asylums provided long term life admissions and routines within them were strict, often involved manual labour and treatments of their time which were often ineffective - Lobotomies were quite commonplace, as was ECT (Electro-convulsive Therapy) and aversion therapy to 'treat' homosexuality. In 1948 the NHS became responsible of 100 asylums with an average population of 1500 patients - some, such as Colney Hatch in Middlesex, Whittington in Lancashire and Claybury in Essex had populations of between 3000-4000 patients. By 1953 almost half of NHS beds were being used for mentally ill/deficient patients. In 1954 Winston Churchill's government commissioned the Percy Report which in 1957 set the course to move services into the community by recommending that mental illness should be regarded in the same way as physical health and disabilities, and that psychiatric hospitals should become the same as 'normal' hospitals. The 1959 Mental Health Act brought the commissions principles into legislation, excluded 'promiscuity alone' as grounds for incarceration and abolished the distinction between psychiatric and other hospitals. One of the biggest milestones within mental health occurred in Brighton in 1961 during the National Association for Mental Health conference, when the Health Minister Enoch Powell signalled the end of the old asylums with his historic "water tower" speech which led to the demonization of psychiatric hospitals. The 1971 Department of Health and Social Security document 'Hospital Services for the Mentally Ill' and the 1975 white paper 'Better Services for the Mentally Ill' helped to drive forward innovations in the treatment and care of the mentally ill. During the 1970's the introduction of medication improved the ease of treatment outside of institutions and psychiatrists began to move away from traditional treatments. The introduction of new General Hospitals which provided some mental health services helped to reduce the number of beds used for mental health to 80,000 in 1975 - compared with 150,000 in the mid 1950's. The Mental Health Act of 1983 gave more rights to the mentally ill and allowed appeals against committal. In 1988, following the conviction of Michael Stone for the murder of Lin Russell and her daughter Megan, the government commissioned an inquiry into care in the community - Community Care: Agenda for Action (The Griffiths Report) leading to the introduction of The National Health Service and Community Care Act in 1990 which stated it was a duty for local authorities to assess people for social care and support. The National Service Framework for mental health in 1990 set quality standards for mental health services, combatting discrimination against individuals and groups with mental health problems, making it easier for people to access services available and created new services to prevent or anticipate Crises. b) The use of community care Community care is any care you receive in relation to managing a mental health problem whilst living in the community and not in hospital. It involves treatment (medication; talking therapies - CBT, counselling and psychotherapy); support from specialist teams (including psychiatrists, CTT - Community Treatment Teams, care co-ordinators); Crisis and liaison teams (which are often attached to Accident and Emergency departments) and Street Triage Teams who support police in the community when dealing with mentally ill patients. Some care is short term (Crisis services, Psychiatric Liaison Teams, Street Triage) while other services are more long term (Community Treatment Teams, Specialist Treatment Teams). The use of community care is fundamental to the movement to remove the social stigma of mental health, it benefits patients in that they can be treated without the added stress of admission to hospital, and for those accessing longer term care the allocation of named professionals involved in their care means that positive relationships can be forged, which will in turn benefit the patient as we draw strength from positive relationships around us in order to deal with mental health issues. Community based care helps to develop independence and supports people towards recovery. Q6 Explain the impact of changes in mental health care by: a) Explaining mental health care in mental hospitals before the introduction of community care Before the introduction of community care mental health care was carried out in asylums. This could cause negative effects on patients rather than having a positive impact. Patients became institutionalised and would be unable to cope without the regular routines of the hospital and could become incapable of independent care. Care was often medication focused rather than a balance of medication and therapeutic treatments. Patients only had other mentally unwell patients to socialise with so they learnt the social 'norms' of the environment and could struggle to emulate 'normality'. b) Explaining how mental health care is delivered in the community Mental health care within the community is made up of 2 parts - Healthcare, which is the responsibility of the NHS; and Social care, which is arranged by the local authority social services. Due to government policies and different ways of funding services, health and social care are becoming more integrated and intermingled. Voluntary and charity services also play an integral part in community care. In order to access most community-based services, you will need a referral from a health or social care professional, such as a GP or social worker, although short term services such as Crisis and Psychiatric Liaison will often accept self-referral. The most common starting point would be an appointment with a GP, who can prescribe medication if they felt it was needed or refer you to local talking treatments. If the GP felt your needs were more complex or long term in nature then they could refer you to a Community Mental Health Team or other specialist service. Once a referral has been made, be it from a GP or a self-referral, then an assessment appointment would be issued and you would be assessed to ensure you have been referred to the most appropriate service for your needs. Everyone is an individual, and there is no 'one size fits all' within mental health services - your care should be as individualized and tailored to your needs as it possibly can be. c) Outlining examples of professional health care roles that have an impact on the delivery of mental health care in the community There are many professional health care roles within community based care services. Some examples are below. A GP provides a complete spectrum of health care in the community. GPs are, for most people, the first point of contact with the NHS for both physical and mental health care. A community mental health nurse (CMHN), also often called a community psychiatric nurse (CPN) is a registered nurse with specialist training who works with you if you receive community-based mental health care. They have different specialisms, such as Learning Disabilities, addiction problems, children and young people and the elderly. Social workers can support with practical matters such as benefits, accommodation and day to day care. Psychiatric social workers specialize in helping the mentally ill access services, they can support to find work or claim welfare benefits and can help in supporting the family and carers. A Care Coordinator is a named individual, often a nurse or social worker, who is designated as responsible for the organisation for a person’s ongoing care. A therapist provides therapy or talking treatments. They may be a counsellor, psychotherapist, psychologist or psychiatrist, if part of their role involves providing therapy. A psychiatrist is a medically qualified doctor who has undertaken further training to specialize in mental health. Some psychiatrist specialize in a particular field, for example perinatal services (for pregnant and new mothers), children and young people or forensic services (for people who are in contact with criminal justice system). A psychologist considers the thoughts, feelings and motivations behind our actions. They provide talking treatments, such as cognitive behaviour therapy (CBT) and psychotherapy and they may also offer individual, group, couple or family therapy. A community mental health team (CMHT) is the team responsible for organising and coordinating care if you receive community-based mental health care. This includes carrying out mental health assessments, treatment and care. You are normally referred to a CMHT if you have complex mental health problems and need more specialist help than a GP can offer. A CMHT will be comprised of a range of different mental health workers, such as psychiatrists, psychiatric nurses, social workers and occupational therapists. A crisis home resolution treatment team (CRHTT) offer intensive support in the event of a mental health crisis (having thought, plan or intent to self-harm or being suicidal). Their aim is to support to aid recovery whilst avoiding hospital admission. CRHTT will visit a person in their home or GP surgery, often daily and as a person recovers they will reduce visits and liaise with other specialist services to refer the person to the most appropriate service for their needs. Q7 Explain the difficulties that individuals with mental health problems may face in day to day living. (2.3) As each person who suffers with mental health problem is an individual, so the effects of that mental health on a person vary greatly. Some of the difficulties that individuals with mental health problems may face in day to day living are as follows. A person’s performance and ability to carry out work which was previously second nature to them may become impaired, in a recent survey by Price Waterhouse Coopers, 34% of people surveyed had taken time off work due to sickness and of them 2 in 5 stated mental health as the issue. Many people who suffer from mental health problems can lose interest in their daily life and begin to withdraw from friends, family and things they have previously enjoyed, shunning social contact and becoming less communicative - often showing less affection for family members and loved ones. They can experience a loss of interest in their appearance and deterioration on their self-care and personal hygiene - they may need prompting to carry out daily tasks as it becomes more difficult. Depression sufferers often cannot make decisions or carry out tasks that they would normally do so. Some people with mental health problems can suffer hallucination which can seem so real that the person may not realise that what they are experiencing is actually false and this can cause difficulties in performing everyday tasks. Some anti-psychotic medication can cause weight gain which may have an impact on physical health and capabilities to carry out simple tasks. Alcohol can interact with medication negatively and alter people’s moods and emotions. There is an increased risk of suicide for people diagnosed with bi-polar disorder and schizophrenia and suffering depression - they often believe they have nothing to live for and can feel they are a burden to others. Many bi-polar sufferers while manic will spend unusually high amounts of money and accrue large debts through risky decision making - this will obviously impact on family life and can in turn put added pressure on relationships. The worse a person’s mental health is the bigger the impact on their daily life. Section 3 - The social context of mental illness Q8 Describe social and cultural attitudes to mental illness including reference to discrimination and stereotyping. (3.1) "Around 1 in 4 people will experience a mental health problem this year yet the shame and silence can be as bad as the mental health problem itself "(www.time-to-change.org.uk). People with mental health problems are some of the most disadvantaged people in society due to negative social and cultural attitudes, discrimination and stereotyping. Stigma (disapproval associated with a particular characteristic/group), prejudice (an affective feeling towards someone not based on reason or actual experience) and discrimination (unjust or prejudicial treatment based on the perceived category a person belongs to) are often based on fear of the unknown so the move towards more community based care may create more positive attitudes as mental health becomes more familiar and commonplace to others, rather than not seen as previously when sufferers were shut away 'out of sight' in institutions. A lot of people with mental illness can feel isolated and suffer from low self-esteem. Stigma, a lack of understanding and knowledge, and discrimination can make their conditions worse. People with mental health problems are often bullied due to their illness which can exacerbate low self-esteem and affect people throughout their lives. The fear of discrimination and stigma can make it difficult for people to ask for help and to discuss things openly with family, friends and peers. Stereotyping (over-generalised belief, usually negative, about a particular category of people based on one characteristic or assumption) can lead to prejudice, discrimination and inequality. It can result in the oppression of others by those in authority; exploitation of others; and mind conditioning leading people to believe in their own stereotype and therefore living up to that expectation. Studies have suggested that often people’s limited knowledge of mental illness can lead to stereotyping and discrimination. For example: * Schizophrenia is often thought to mean having a spilt personality and is seen as dangerous, this is not true - it is actually a long term and complex mental health condition which can involve hallucinations, delusions and changes in behaviour. * Alcoholics and drug addicts are often thought of as dangerous and responsible for their own addictions - addictions is actually not having control over doing, taking or using something to the point it could become harmful and it is possible to become addicted to almost anything - work, shopping, exercising, internet as well as more commonly alcohol, drugs and gambling. In 2007, Time to Change, a social movement aiming to change and improve the social attitudes towards mental health was started. It regularly runs campaigns using social marketing to engage audiences in order to positively change attitude towards mental health and reduce social stigma. In 2017, results from a National Attitudes to Mental Illness Survey revealed that since 2009 there had been: * 15% increase in willingness to live with someone with a mental health problem (up to 72%) * 11% increase in willingness to work with someone with a mental health problem (up to 80%). * 10% increase in willingness to live nearby to someone with a mental health problem (up to 82%) * 6% increase in willingness to continue a relationship with a friend who had a mental health problem (up to 89%). The survey also indicated that people who personally knew someone with a mental health problem were more likely to have positive attitudes. An increased understanding of mental illness can lead to more positive social and cultural attitudes. Q9a Describe how mental illness has been portrayed by the media in films and newspapers. (3.2) a) Films Mental health within films is generally sensationalised to focus on major events for maximum impact and is not often portrayed accurately. When thinking of films relating to mental health certain well known ones spring to mind. PSYCHO (1960) - this film focused on dissociative personality disorder and the vicious murder of a young woman by a man suffering from this condition, it also touched on the subject of transgender and transsexual. The film while widely viewed as one of cinema greats held previously unknown levels of violence and nudity and fed into the stereotype that sufferers of DID are prone to violence and are dangerous. FATAL ATTRACTION (1987) - this film about a short-lived affair between a married man and single woman portrayed the woman as a psychopath with erotomania (where a person wrongly believes someone is in love with them) and a borderline personality disorder. As the film progresses she becomes more violent and dangerous and suffers with impulsive emotional lability. James Dearden, the screenwriter said "To turn it into a mass-audience film, I knew there would have to be an escalation of the psychological violence, which in the end becomes physical." The ending of the film results in the death of the single woman, shot dead by the wife (the only untainted character within the film) of the man - this was to provide a 'statement' on the preservation of the family within America and allow for moviegoers thirst for revenge. SILENCE OF THE LAMBS (1991) focused on a highly intelligent, brilliant and manipulative psychiatrist who is also a cannibalistic serial killer, helping the FBI to catch another serial killer who skins his young female victims alive. It touches on the subjects of being transsexual and bisexual, cannibalism and being a psychopath. It portrayed both of the mentally ill in the film as violent and dangerous. SPLIT (2016) - this film focused on a man with 23 different personalities who kidnaps and imprisons three teenage girls in an isolated underground facility. Similarly to PSYCHO it reinforces the false stereotype that people with dissociative identity disorder are dangerous and violent. There are, however a few films which depict mental health in a more positive and realistic way. SILVER LININGS PLAYBOOK (2012) depicts a man suffering with bi-polar who has recently been discharged from hospital and a woman who has unspecified mental health issues. They have both suffered recent loss in the breakdown of a relationship and a bereavement and the film follows their journey as they struggle to cope and support each other. The film has been described as capturing a well-rounded sense of bipolar disorder without glamorizing mental illness or sugar-coating it and in addition to portraying mental illness in a humanizing and relatable way it strives to show that everyone is struggling with something. FROZEN (2013), an animated Disney film about 2 sisters. The film, for many, shows an accurate portrayal of anxiety and depression, and on social media Jennifer Lee, the writer and director confirmed that this was intentional. Throughout the film, Elsa (one of the sisters) struggles with her emotions and feelings, but the message that comes through by the end of the film when Elsa is learning to control her powers if that you can't always 'cure' a mental illness, but you can treat it and learn to live with it. b) Newspapers How mental health is reported in the media can be incredibly powerful in educating and influencing the public. Sensational journalism can exaggerate the risk of violence, encourage fear and mistrust and isolate sufferers further. Factual reporting can be an effective tool to raise awareness and challenge prejudice and stereotyping. Tabloid coverage often focuses on attention grabbing headlines, stigmatising people with personality disorders and using language with negative undertones, for example psycho, insane. In 2013 The Sun newspaper ran a headline "1200 KILLED BY MENTAL PATIENTS", the article stated this was over a decade and went on to show photographs of victims alongside the perpetrators of the crimes and blamed failings with the mental health system in Britain. NCISH (2014) reports that during 2002-2012, 576 people convicted of homicide (10% of the total sample) were confirmed as having been in contact with mental health services in the 12 months prior to the offence. This represents an average of 52 homicides per year. There were 613 victims, an average of 56 per year. The above example show just how misleading headlines can be as they are written to grab the attention and influence the reader. Q9b Describe how the media’s coverage of mental illness can influence attitudes in the general public. (3.2) Mass media has an incredible power to shape and influence attitudes towards the mentally ill, however when reporting on this issue it can often be misleading and skew reality. Selective reporting on a series of tragedies, including the murder of Jonathan Zito by Christopher Clunis and the killing of the Russell family by Michael Stone, created a widespread fear that violent mental patients were roaming free within the community; however mentally ill patients can arguably be classed as less dangerous than drunk drivers. Between 2006 - 2016, according to statistics from www.drunkdriving.org, 3370 people were killed in the UK by drunk drivers - of the almost 6000 murders committed in the same time frame, 11% or approximately 660 were killed by mentally ill patients. In recent times, campaigns to bring mental health into the forefront of discussion and to lower stigma and stereotyping have shown some success in improving the attitudes towards the mentally ill. Social media campaigns such as #it's ok not to be ok; #time to change; #heads together (a high profile campaign fronted by The Duke and Duchess of Gloucester and Prince Harry) are creating discussion between and making younger people of the issues of mental health. The more positive coverage of mental illness and the more discussion generated by this coverage will result in less stigma and therefore discrimination. Q10 Explain the impact that social and cultural attitudes to mental illness can have on individuals and their care. (3.3) The Mental Health Foundation website states "Nearly 9 out of 10 people with mental health problems say stigma and discrimination have a negative impact on their lives". People with mental illness are less likely to find work, maintain a steady long-term relationship, live in decent housing - often because social stereotyping has them labelled as dangerous and violent when they are, in fact, more likely to harm themselves than others. Names used to describe sufferers of mental health have a detrimental effect on their mind-set and personal self-image - being called names such as 'mad', 'crazy', 'nuts' or 'psycho' is not going to promote a healthy self-esteem. Because a mental illness is not something you can see, some people find it hard to believe it is there, and if they have never suffered or been in contact with someone who suffers with their mental health it can be difficult to have an understanding or empathy, for example: CASE STUDY - N, age 53 had never suffered with mental illness previously. He had no real contact with anyone suffering from mental illness and very little understanding of the issues they face. He presented to his GP after being made to go by his fiancé - he felt he should just be able to 'get on with it' and had told his fiancé he felt 'stupid for not coping'. He had severe anxiety brought on by stress at work. For 6 months N was off work due to an inability to function on a daily level. He could not leave the house without company, any outing from the house would be preceded by an hour of sweating, palpitations, vomiting and nose bleeds. His job was highly pressured, involved lots of contacts with suppliers, transporters and foreign clients. N's anxiety was so crippling he would have to 'psych himself up' for 15 minutes in order to make a simple phone call to his fiancé and partner of 12 years. N's partner worked in mental health services and had a good understanding of what he was going through - N attended counselling for several weeks and this alongside medication meant he made a good recovery and has strategies and coping mechanisms he can use should the anxiety begin to return. Since his experience with anxiety N is now more aware of the issues facing the mentally ill on a daily basis and has changed some of his social circle, becoming more tolerant and supportive of others and being more willing to openly discuss how he had felt at the time. A negative social attitude to mental illness can prevent people seeking help and care for their conditions - people are reluctant to access services feeling they may be "taken away" or "put in hospital" for asking for help. Some people can experience their whole family being treated with suspicion or as 'untouchables' often demonstrated in body language, by staying away, by staring, making fun of them or ignoring them on the street. This kind of behaviour hurts people and affects social and family life and can divide communities. Different cultures have different attitudes to mental health, for example: ASIA - In Asia many cultures value the conformity to norms; recognition through achievement and emotional self-control, this means that mental illness can be seen as a source of shame within the family and community. AFRICA - In traditional African society, there is a historic culture of strong beliefs in the existence and activities of witches, ancestral spirits, sorcerers etc., and it is still strongly believed that an individual's well-being can be influenced through the subtle manipulation of those entities. In October 2012, Human Rights Watch released a report on Ghanaian sufferers of mental illness shedding light on the presence of spiritual healing centres, run by independent faith healers. Nearly all patients in the eight centres inspected were chained to trees by their ankles and left to sleep, urinate, defecate and bathe in that same spot. NATIVE AMERICANS - In Native American culture sufferers of depression, anxiety or substance abuse are more likely to use alternative remedies and seek help from spiritual leaders rather than medical support. A high level of poverty among the Native Americans also prevent many from accessing health care. Only by working to improve social and cultural attitudes to mental illness will we begin to see less negative impact on the sufferers of mental illness and an improvement in their ability and willingness to access care and improve the impact of the illness on the individual. Section 4 – The Legal Context of Mental Illness Q11 Identify examples of relevant legislation in relation to mental illness including a brief description of each one. You should clearly state the name of each legislation you include in your answer. (4.1) THE MENTAL HEALTH ACT (MHA) 1983 deals with the assessment, treatment and detention of people with a mental disorder. It also gives the legal rights of a person following their compulsory admission into hospital. It relates to people who have a mental disorder; allows people to be detained who are a threat to themselves or others; different sections of the act allow for people to be 'sectioned' under different conditions; it allows for people to be treated without their consent (some treatments must be consented to) and allows for detained patients to apply for their own discharge. THE NATIONAL HEALTH SERVICE AND COMMUNITY CARE ACT 1990 gave the responsibility for assessing people's needs, planning and providing care to local authorities. This includes domiciliary care; day services; respite care and carers support. Anyone can make a referral to social services on a patient's behalf; the local authority must assess anyone appearing to need a care service, provide a written care plan and, with consent, GPs are expected to share relevant information to aid in assessment. THE CALDICOTT REPORT 1997 was commissioned due to an increase in concerns involving the use of patient information within the NHS and decided that all information which could reveal a person’s identity must be protected to safeguard confidentiality. The 6 main principles of the report were to: (i) justify the purpose of holding patient information; (ii) only hold information on a patient if absolutely necessary; (iii) use only the minimum of information that is required; (iv) access to information should be on a strict need to know basis; (v) everyone in the organisation should be aware of their responsibilities; (vi) the organisation should understand and comply with the law. THE HUMAN RIGHTS ACT 1998 deals with the protection of a range of human rights to ensure that all people are treated equally. It protects people with mental health problem in 2 ways; (i) every law should be compatible with human rights contained within the European Convention on Human Rights (in the UK this includes the MHA 1983 - should part of this act not comply then parliament needs to change the law) (ii) Mental health practice should comply with human rights. Staff and providers of services must ensure they do not breach the human rights of service users. THE MENTAL CAPACITY ACT (MCA) 2005 was aimed at safeguarding those people who were unable to make decisions for themselves due to a 'lack of capacity' through mental health problems. The Office of the Public Guardian and The Court of Protection were introduced to ensure these individuals were fairly treated. 5 key principles underpin the MCA. (i) presumption of capacity - everyone has the right to make their own decisions and is presumed to have capacity unless proved otherwise. (ii) support to make own decisions - all practicable help should be given to allow a person to make their own decision. (iii) unwise decisions - everyone has the right to make a decision others may view as unwise or eccentric. People’s values, beliefs and preferences may not be the same as other people. (iv) best interests - anything done for, or on behalf of a person who lacks capacity must be done in their best interests. (v) less restrictive option - anyone making a decision or acting on behalf of a person who lacks capacity must consider if there is another way which would interfere less with that person’s rights and freedoms of action. THE MENTAL HEALTH ACT 2007 (MHA) was to amend the MHA 1983 in order to bring it into line with The Human Rights Act 1998. It amended the MHA 1983 by changing the definition of mental disorder; introducing a new criteria for detention; allowing someone detained to be discharged into the community to access treatment, subject to recall to hospital if required; providing age appropriate services; placing a duty on national authority to provide mental health advocates; introducing new safeguards for patients undergoing Electro-convulsive Therapy. It also amended the MCA 2005 to protect against the deprivation of liberty for people lacking the capacity to consent to arrangements being made for their care which would deprive them of their liberty. THE HEALTH AND SOCIAL CARE ACT 2008 contained significant measures to modernise and integrate health and social care. In relation to mental health care it established the Care Quality Commission to regulate the quality of care provided and the education, training and registration of relevant professionals. THE EQUALITY ACT 2010 brought together all previous anti-discrimination laws under one piece of legislation. It applies to everyone providing a public service; covers statutory, private, voluntary and community organisations; prohibits discrimination on grounds of 'protected characteristics' such as age, gender, race, religion, disability, sex, sexual orientation, marriage, and pregnancy. In addition to direct discrimination. The act also prohibits indirect discrimination, harassment and victimisation. In relation to mental health it placed legal obligations on everyone providing or working in mental health care around training, reviewing under-represented groups of service users and ensuring employees follow procedure and policies within the workplace relating to equality and diversity. THE CARE ACT 2014 introduced new responsibilities and duties for local authorities. Under the act local authorities must: (i) carry out an assessment of anyone who appears to require care and support, regardless of their likely eligibility for state-funded care. (ii) focus the assessment on the person's needs and how they impact on their wellbeing, and the outcomes they want to achieve (iii) involve the person in the assessment and, where appropriate, their carer or someone else they nominate (iv) provide access to an independent advocate to support the person's involvement in the assessment if required (v) consider other things besides care services that can contribute to the desired outcomes (e.g. preventive services, community support) (vi) use the new national minimum threshold to judge eligibility for publicly funded care and support THE GENERAL DATA PROTECTION REGULATION 2016 (GDPR) deals with the safeguarding of confidential information about individuals. It gives individuals the right to know what information is held about them. There are 6 main principles in the GDPR and anyone handling information must comply with the principles which are: (i) Information must be processed fairly, lawfully and transparently in relation to the data subject (Care workers should have the individuals consent to collect and use the individual’s information and be entitled to handle the information. Individuals have the right to know how information is used, to have errors corrected and prevent information being used for advertising or marketing). (ii) Information should be collected for specific, explicit and legitimate purposes. It should not be used for anything other than what it was obtained for. (iii) Information should be adequate, relevant and necessary - only information needed should be collected. (iv) Information should be accurate and up to date. All errors should be corrected and care workers should not handle personal or sensitive information which is not relevant to their role. (v) Information should be kept safe, destroyed when no longer needed and individuals have the 'right to be forgotten' (they can request their personal information is erased and no longer processed. (vi) Information should be kept safe at all times, protected from unauthorised access, disclosure and destruction. Any breach of personal data should be reported to the Information Commissioners Office (ICO) without undue delay and preferably within 72 hours of realisation. Q12 Outline the implications in legislation for the provision of care to an individual with mental health problems. Illustrate your answer with reference to specific pieces of legislation. (4.2) In the majority of cases, when a person is being treat in a hospital or other mental health facility they are there voluntarily, having either agreed to or volunteered to be there. Under The Mental Health Act 1983 (M,HA), which relates to people who have a mental disorder a person can be detained or 'sectioned' and treated without their consent. A person can be detained under different conditions, depending on which 'section' is carried out - the most common are listed below. Under a section 2 a person can be detained for up to 28 days for assessment of the individuals mental state and 2 appropriate doctors are required to carry this out. Under a section 3 you can be detained for up to six months for treatment and 2 appropriate doctors need to apply for this. Under a section 135 a warrant is needed, police can enter your home, with force if needed and you may then be taken to a place of safety for an assessment by an approved mental health professional and a doctor. You can be kept there until the assessment is completed for up to a maximum of 36 hours. Under a section 136, if you are in a public place and you appear to have a mental disorder and are in need of immediate care or control, the police can take you to a place of safety (usually a hospital or sometimes the police station) and detain you there. You will then be assessed by an approved mental health professional and a doctor. As with a section 135, you can be kept there until the assessment is completed, up to a maximum of 36 hours. Most patients who are detained have the right to apply for their discharge and this is decided by an independent tribunal. Under the National Health Service and Community Care Act 1990 everyone is legally entitled to an assessment of their needs to access community care services. The assessment is carried out by the local authority and the individual can referred for the assessment by anyone. All staff and providers of services must comply with The Human Rights Act 1998 and ensure that the human rights of service users are not breached. The Mental Health Act 2007 amended the MHA 1983 to bring it into line with the Human Rights Act 1998. The introduction of a new 'appropriate medical treatment' test which applies to the longer-term powers of detention. This meant it is not possible to detain someone or have their detention extended unless medical treatment appropriate to the patient's mental disorder is available. It also introduced a Supervised Community Treatment (SCT) which meant in certain circumstances someone who has been detained for treatment can be discharged on a Community Treatment Order (CTO) to continue their treatment in the community, subject to possible recall if necessary. Q13 Outline legal provisions for individuals who are unable to make decisions for themselves due to mental health problems. (4.3) Legal provisions for individuals unable to make their own decisions due to mental health problems are covered by the Mental Capacity Act 2005 (MCA) and part of The Mental Health Act (MHA) 2007. The MCA 2005 empowers people, wherever possible, to make their own decisions and protects people who have lost the capacity to make their own decisions by providing a framework placing the individual at the heart of the decision making process. It also allows for people to plan ahead for a time in the future where they may be unable to make their own decisions. There are 5 key principles to the MCA 2005. 1. A presumption of capacity - every adult has the right to make their own decisions and should be assumed to have capacity to make those decisions unless it is proved otherwise. Just because someone has a particular medical condition or disability does not mean they cannot make their own decisions. 2. Individuals are supported to make their own decisions - every effort must be made to encourage and support an individual in the decision making process. Should a lack of capacity be established they should still be involved, as far as it is possible to do so, in making the decisions that affect them. 3. Unwise decisions - just because someone may make a decision we do not agree with does not make this a wrong decision. Everyone has different thoughts, beliefs and preferences and an individual had the right to make decisions based on their own values, even if they could be construed as an unwise decision. 4. Best interests - any decision made for or on the behalf of someone with a lack of capacity must be done in that person's best interests. 5. Less restrictive option - Anyone making a decision for or on behalf of someone deemed to lack capacity must consider whether or not it is possible to decide or act in a way which will cause the least interference with that person's rights and freedom of action, or indeed if there is a need to decide or act on that person's behalf at all. Each case and decision should be taken on an individual circumstance of the person's case. There are many roles, bodies and powers which support the MCA. Lasting Power of Attorney (LPA) which replaced the Enduring Power of Attorney (EPA). The LPA allows an adult to formally appoint people to look after their health, welfare and financial decisions in case of a time in the future that they lack the capacity to make those decisions themselves. The Court of Protection and Deputies was introduced to protect people who lack capacity and to supervise those making decisions on their behalf. The court can appoint a deputy and will tailor the deputies’ powers to meet the needs and circumstances of the individual. A Public Guardian's role is to support and protect those who lack capacity from abuse. The Office of the Public Guardian (OPG) is a body which supports the Public Guardian, maintains a register of LPAs and maintains the register of court appointed deputies and supervises them. Independent Mental Capacity Advocates (IMCA) are a statutory safeguard. They are there to help those lacking capacity make some important decisions should they not have family or friends who can represent them. IMCAs can make decisions about where a person lives and also around serious medical treatment. They represent individuals during adult protection proceedings. The MCA created statutory rules with clear safeguards so that individuals may make a decision in advance to refuse treatment should they lack capacity at the time that decision needs to be made, and it introduced a criminal offence of the ill treatment or wilful neglect of a person lacking capacity. The MHA 2007 made changes to the MCA 2005 by introducing the Deprivation of Liberty Safeguards (DOLS). This was in response to the lack of a procedure to challenge the deprivation of liberty of a person lacking capacity to give consent while residing in a hospital or care home. DOLS were introduced to protect people who do not have capacity to consent to arrangements for their care that would deprive them of their liberty. Deprivation of Liberty is only authorised if identified by an independent assessment as a necessary and proportionate action to prevent a person from harm. Q14 In relation to individuals with mental health problems, outline the legal issues relating to: (4.4) a) Confidentiality There are several legal issues relating to confidentiality for individuals with mental health problems. There will, inevitably, be some conflict between the need to respect the confidence of those whose personal information is held and the desirability, and sometimes necessity, of sharing information with professionals, family members and Carers in the interests of an individual, their family or the wider community. Human rights are protected within the UK by The Human Rights Act 1998 - one of these rights is the "right to respect for family and private life, home and correspondence". Public Authorities (including Health and Social Care Services workers acting in the course of their employment) can override that right but ONLY where it is in the interest of public safety, for the prevention of crime or the protection of health. Should personal information be disclosed without consent for any purpose other than stated previously this could be seen as a breach of this right. The Freedom of Information Act 2000 means that documents within health trust can be accessible to anyone. Should anyone request information which contains personal information then disclosure of detail will only be permitted if data protection conditions are met. Section 60 of the Health and Social Care Act 2001 gives the Secretary of State the powers to permit the use of patient data without consent, but only in special cases. If a person lacks capacity to make decisions or manage their own affairs then a person acting under an order of the Court of Protection or acting as a registered Enduring Power of Attorney can consent to sharing of information on that persons behalf. There may be a legal obligation to disclose information in order to comply with an obligation imposed on an authority. In this case the consent of the individual is not necessary. Authorities should, however, inform the individual that such an obligation exists. The increase in the use of Information Technology in the 1990's led to a review of the use of patient identifiable data. This review was led by Dame Fiona Caldicott in 1997 and 6 main 'Caldicott Principles' were recommended to ensure the protection of patient identifiable data. These principles stated that: 1. The purpose of sharing the information must be justified 2. Information should only be used if there is no other alternative 3. Only the minimum required information should be recorded. 4. Information access is restricted and should only be shared on a 'need to know' basis. 5. People with access to information must be aware of their responsibilities to ensure the confidentiality of the information. 6. Everyone with access to the information must understand and comply with the law. In addition to these six principles it was recommended a senior person within each health organisation be nominated as a 'Caldicott Guardian' with responsibility for ensuring the safeguarding of confidentiality within their organisation. In July 2016 a further review was undertaken to improve the use of data in peoples interests and ensure transparency about when data will be used and when people can 'opt out' of the usage of their data. b) Data protection Legal issues relating to data protection for individuals with mental health problems are covered by The General Data Protection Regulation 2016 (GDPR). This regulation was bought into place to ensure that information is safeguarded and it gives individuals the right to know what information is held about them. A person must give permission to collect and use information and the person collecting the information should be entitled to handle the information. Any information held should be accurate and any errors should be corrected and individuals have the right to know how their information will be used. Information should only be used for the purpose for which it was collected and only as much information as is needed should be obtained. Care workers should not handle any personal or sensitive information which they do not need to know in order to carry out their role. All information should be stored safely and securely, protected from unauthorised access, disclosure, alteration or destruction. Should a data breach occur it should be reported to the Independent Commissioners Office within 72 hours. When information is no longer needed then it should be destroyed and individuals have the right to request the erasure of their personal data and 'be forgotten'. The retention of data may be necessary in some cases for compliance with a legal obligation or for a reason of public interest. Sharon Makinson Level 2 Awareness of Mental Health