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Creating digital tools for mental health and employment support: the discovery phase


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This report maps out the needs of potential users of an online mental health and work assessment and support service, suggests key user groups and presents a set of design principles for any a potential future service.

Published in: Government & Nonprofit
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Creating digital tools for mental health and employment support: the discovery phase

  2. 2. The Point People focused on maximising the impact of social innovation initiatives. We are a mix of social researchers, policy analysts, social entrepreneurs, artists and innovators. We’ve been commissioners, evaluators and recipients of funding. We’ve run big government programmes and started small social enterprises. We’ve led incubation programmes for young innovators and provided strategic support to senior executives. We’ve campaigned from the outside and reformed from the inside. Between us, we’ve been there. Co-Director, Jen Lexmond has over seven years experience leading qualitative and quantitative research programmes in the fields of mental health, human development, and social mobility. Co-Director Ella Saltmarshe is a trained anthropologist with over a decade’s worth of experience working with NGOs, donors and higher education institutions. WHO WE ARE THE POINT PEOPLE Snook is a Service Design agency based in Glasgow who specialise in designing exceptional customer experiences that are joined up and work for people, with a distinct focus on innovation in the public domain. Snook have worked for the past 5 years across the public sector including clients from the NHS, Scottish Government, 3rd sector agencies and local authorities across the UK. They have depth of knowledge in the field of Mental Health and Employment working with health boards in Scotland to research the impact of technology on mental health and continuing to build digital products for the Mental Health sector in partnership with the NHS and EU. Sarah Drummond is the co-founder and managing director of Snook. Sarah focuses on making social change happen by re-thinking public services from a human perspective. Dr Valerie Carr is a creative director at Snook with over 30 years experience in the design industry. With a PhD in Healthcare Service Design her expertise has been utilised by a diverse range of organisations from the NHS to Shell. SNOOK
  3. 3. WHO WE ARE Roberta Knox is a design researcher at Snook responsible for delivering Project 99, a cutting edge research project with NHS Greater Glasgow and Clyde looking at young people, technology and Mental Health. The Point People and Snook worked in partnership with a range of stakeholders throughout the discovery phase, including: Department of Health Lauren Jones Clair Harrigan Rebecca Handley Louise Warner Department for Work and Pensions Carl Neenan Hayley Moore-Purvis Maxine Willetts Shaun Donaghy Government Digital Service Leisa Reichelt
  5. 5. TABLE OF CONTENTS 1. INTRODUCTION Purpose This Report 2. EXECUTIVE SUMMARY 3. DESIGN BRIEFS: Finding work User Needs Insights Case Studies In and out of work User Needs Insights Case Studies Management work User Needs Insights Case Studies 4. INSIGHTS Mental Health Support Employment Support Where Digital Adds Value 5. DESIGN PRINCIPLES 6. APPENDICES Methodology Hopes & Fears Demographics Tables
  7. 7. A recent report from RAND Europe (Autumn 2014) commissioned by the Department of Health examined the existing evidence on mental health interventions and made some recommendations for new support services that would help fill existing gaps in provision by: • Providing earlier access to specialist services • Addressing both employment and mental health needs • Introducing more integration between current services or propose new or innovative applications of existing evidence-based models In particular, they suggest developing a pilot to “provide access to online mental health and work assessment and support….open to the general population”. This document reports back on a first phase of primary research to identify and better understand the potential user groups for such a service, and to map out the needs and experiences of potential users of this service into a set of early design briefs. This report, therefore, corresponds to the Government Digital Service’s (GDS) ‘Discovery phase’ in their methodology for designing new, effective digital services. It serves as a series of design briefs for the subsequent development of a series of prototypes. PURPOSE
  8. 8. INTRODUCTION / PURPOSE THIS REPORT This report brings together what we’ve learned through the Discovery phase and synthesises insights into user needs structured around three sections of the employment journey: • Finding work • In and out of work • Managing work Each section is intended to be read as a design brief that will inform the next stage of this research (Alpha) either to design new products and services or to re-design existing services in the field of mental health and employment. To support this, we have taken the insights from the Discovery phase and turned these into actionable user needs. They remain open to interpretation but lead towards a designed set of functions (on and offline) for supporting people to be fit for work and mentally well. Each design brief contains: User needs that highlight common needs that individuals in a user group have around mental health and employment, and makes the link to a type of service or tool that would help them address that need, or prevent that need from arising in the first place. Insights about what different people within one user group have in common Challenges that different people within one user group are all facing Case studies of real people struggling with mental health and employment concerns, from a wide variety of backgrounds
  10. 10. IDENTIFYING USER GROUPS MENTAL HEALTH The scope of ‘Discovery’ phase research was limited to individuals with common mental health concerns or conditions. We learned quickly that knowing whether an individual’s condition is diagnosed or undiagnosed does little to shed light on the severity of their condition, or the extent to which they are successfully managing their condition. Therefore, the user groups ‘diagnosed’ and ‘undiagnosed’ are not particularly meaningful categories to inform the design of a new digital tool or service, although it may be relevant in identifying channels for reaching those individuals. A new digital service could also be relevant to those with more severe issues but who are managing their condition well, for example through strong support networks or higher levels of personal resilience. In most cases, people with more severe issues need a depth of support that online services are unlikely to be able to provide independently of face to face services. A digital service could work well in conjunction with face to face support, as a supplement or connecting tool. The diagram shows two axes; severity of symptoms and level of management of mental health concerns or conditions. It reflects where stakeholders (Department of Health, the Department of Work and Pensions & the Government Digital Service) see a new digital tool adding the most value.
  12. 12. 1. Never have, never will 2. Was online, but no longer 3. Willing and unable 4. Reluctantly online 5. Learning 6. Task specific 7. Basic digital skills 8. Confident 9. Expert This diagram shows the digital literacy scale (taken from the Government Digital Inclusion Strategy) and reflects where stakeholders (Department of Health, the Department of Work and Pensions & the Government Digital Service) feel a new digital tool could have the most value. DIGITAL INCLUSION SCALE
  13. 13. DIGITAL LITERACY A new digital service should be designed with digital inclusion in mind, as well as an awareness that a basic level of digital literacy will be required from any user of a digital service which has an aim beyond building digital literacy itself. It is clear that a digital service is most appropriate for people who already have basic digital skills rather than those at lower end of the government’s Digital Inclusion Scale. Access to the internet, and to wifi or 3G are likely user requirements, as is a smartphone or laptop/desktop. Clear, simple design, as well as video and audio are important elements for engagement in any digital service. Not only can these elements overcome language barriers and certain disabilities, but they also harness the growing trend for consuming information through audio and visual formats. EXECUTIVE SUMMARY / IDENTIFYING USER GROUPS Our scope was unlimited as regards employment status and interviewees included those in full time or part time employment, those in self-employment and those who were unemployed. Mapping user needs onto a detailed matrix of the employment journey revealed that there is scope for a digital service to respond to needs right across the employment continuum (although it is equally clear that one single tool will not be able to respond to all needs). Looking through the lens of employment, three broad user groups emerge: • Finding work • In and out of work • Managing work EMPLOYMENT
  14. 14. This is a top line visual of the employment journey, drawn from the comprehensive user needs matrix that we used to map the different stages of peoples’ experiences as they transitioned in and out of employment. Examples of the full user matrix are contained in the report appendix. THE EMPLOYMENT JOURNEY
  15. 15. Volunteering Caring Education Training Leaving employment Unemployment Seeking employment Entering employment Employment Leaving Employment
  17. 17. There are many different kinds of unemployment, from people who haven’t worked for many years, to those who are simply in between jobs. Some people classified as unemployed might be very busy in caring roles or volunteering, others might be isolated and struggling to lead an active life. Finding work can be fundamentally confidence sapping, uncertain and stressful. Dealing with anxiety-triggering situations like interviews and the stress of repeated rejection can be especially difficult for people whose self-esteem is already low. Face to face support is important for unemployed people to build confidence and help combat isolation. Hearing success stories from people similar to themselves who have overcome familiar obstacles and found work can inspire and motivate unemployed people. Developing a career direction with long and short-term goals can be inspiring and can enable people to understand their next steps more clearly. It’s important for people with mental health issues to develop self-awareness about the working conditions that are beneficial and detrimental to their psychological wellbeing, and to use that to guide their job search. SUMMARY
  18. 18. FINDING WORK / SUMMARY USER NEEDS UNDERSTANDING WHICH JOBS TO APPLY FOR. As someone who is unemployed, I need a tool that helps me identify my skills because right now I don’t know what I’m good at or where I want to go. Developing a career direction with long and short term goals can be inspiring and beneficial, enabling people to understand their next steps more clearly. “I could do with more help to write my CV because I’ve got a lot of transferable skills, I think.” Peter (51) As someone who is unemployed with mental health issues, I need a tool that will help me search for jobs relevant to my sector and mental health needs, so I can find work that motivates me and is good for me. Self-awareness of the working conditions that are beneficial and detrimental to mental health issues is vital. A tool that enables people to both better understand their optimal working conditions and to search for jobs accordingly, would be valuable. “Where will I find a job that won’t make me a problem?” Zubin (50)
  19. 19. DEALING WITH THE EMOTIONAL SIDE OF JOB-HUNTING. As someone who is unemployed, I need help finding existing services and groups in my local area because face to face interactions really help to build my confidence. Signposting people to existing services is important. Face to face support can be extremely valuable in building self-esteem and combating isolation. “The most helpful thing in terms of looking for work] is meeting people. Meeting different faces. Actually the helpful part of it is me getting off my butt and going to these places. Actually turning up for interviews and actually speaking to someone like you, and actually having a conversation with someone different who I don’t know. I don’t usually do that, I usually am quiet.” Derek (37) As someone who is unemployed, I need encouragement and tools that give me belief in my own abilities, because I have low self-esteem. Unemployment can be fundamentally confidence sapping, uncertain and stressful. “Feeling a fundamental lack of confidence and sureness about the future, not knowing if you are ever going to get a job… Being skint, you know, which brings all the other things like not being able to pay the bills or finding that stressful, getting knock-backs, not hearing from jobs or not getting interviews” Sam (35) As someone who is unemployed, I need a tool that helps me manage rejection, because I face a lot of it and at the moment each one sets me back. People who are unemployed generally have to apply for many opportunities before finding work. If their self-esteem is already low, managing multiple rejections can be very challenging and can stop them from continuing to apply for jobs. “So, I talked myself out of doing lots of things. I got knocked – knock-backs set me back far too long and I, kind of, you know, didn’t get back into it quick enough” Sam (35) As someone who is unemployed with mental wellbeing issues, I need to hear stories from other, similar people, who have successfully found work, so that I can keep motivated. Many interviewees talked of the value of hearing success stories from people similar to them, to both inspire and motivate.
  20. 20. FINDING WORK / USER NEEDS “Other people’s stories about how they felt. I guess that’s something else that gives me some resilience, some belief in myself because I can see that other people have come through it.” Josh (26) As someone recovering from a period of mental ill health, I need positive reminders to support my transition back into work so that I am not just focusing on the negative drivers (financial necessity). One interviewee, Rajesh (25), has had severe bouts of depression and is re- entering the job market via LINK, a transition to employment service from the NHS. He is under considerable financial pressure to start earning to prevent his father from losing their family home. He is a bright young man with qualifications and many skills to offer. Work will bring him all sorts of benefits. He needs something to help him hold onto these more positive factors (the pull) amidst the financial worries (the push).
  21. 21. DEALING WITH THE PRACTICAL SIDE OF JOB-HUNTING As someone with anxiety/depression, I need tools that give me skills and confidence to successfully navigate interviews, because at the moment I don’t believe I can. Job interviews can be a big barrier for people with mental health issues; the pressure and anxiety of having to perform can be debilitating. “Basically I suffer with nerves going to an interview. I get tongue-tied and I don’t know what to say. I just sit there and I don’t say anything, just smile. That’s the only thing I can do.” Derek (37) As someone who is unemployed, I need a tool that will help me write a CV and covering letter relevant to the sector I am applying for, so that I have the best possible chance of getting a job. While there are many services that offer CV and covering letter support, many are generic. Interviewees spoke of the value of quality sector-specific services. “Maybe have CV templates or something, because when I used to go to see my job coach, I’d have something written and then they’d magically make it into something sounding a lot better but it’s the same thing. So something where you can make what you’re writing sound better.” Debbie (22) As someone applying for work, I need a tool that will help me understand when and whether it’s appropriate for me to tell potential employers about my mental health needs, so that I act in my own best interests. Understanding employment rights can be important for people when job-hunting. Often people are unaware of their rights at this stage and lack the confidence to question requests for personal health information by potential employers because they don’t want to miss out on the opportunity of work. “So I walked out of that interview feeling really positive and they said, “We’ll let you know.” They gave me the job but with the proviso that I filled out some health forms. Not knowing at the time that pre-employment health questions are not okay, I filled out a short form. I said, “Look, I have mental health problems.” They then sent me another set of forms which is about eight pages long, detailing my whole history. I did that, they came back to me – this got dragged out over a year – they came back to me and said, “Right, okay. So we’ve got some concerns, can you go and see an
  22. 22. FINDING WORK / USER NEEDS occupational health person… I ended up going to occupational health, had a very long interview that’s about an hour long with a really nice doctor… So two weeks later a letter came through my door. I’m still quite optimistic at this point and the letter says – the letter was written by a supervisor who had never met me – it, basically, said, “We don’t think you’re safe to work with children and young people.” Which… really felt like a slap in the face.” Karen (24)
  23. 23. HELPING PEOPLE BUILD NETWORKS AND EXPERIENCE As someone who is unemployed, I need a tool that will help me find volunteering opportunities in my local area, so I can use my skills, feel a sense of purpose, connect with others and if possible, transition into paid employment. Volunteering plays an enormously beneficial role in the lives of some unemployed people and impacts positively both on mental wellbeing and employment prospects. Interviewees frequently mentioned how it would be useful to be able to find local volunteering opportunities. “I think it can be a bit overwhelming… to go from unemployed to think about full time employed. Shorter jobs, or opportunities to meet people and do other things, so volunteer opportunities…are quite good. But some kind of hub where you can look for opportunities in your area, or people could post opportunities like ‘we need someone to come and get involved.’ That kind of thing.” Susie (31) As someone who is unemployed, I need help to build a professional network, so that I have the best chance to hear about job vacancies quickly and get my foot in the door. Knowing the right people in your sector was deemed the most fruitful route to finding work opportunities and receiving valuable advice. This can be a difficult and daunting task, especially for those with little work experience, and those facing isolating and confidence-sapping mental health problems (or simply the low self- esteem that often goes hand-in-hand with job seeking). “Graduating and finding work from Uni it’s about networking and who you know as well. A lot of graduates in my circle were kind of stuck because they didn’t know where to start and who to contact. I happened to be fortunate because I knew someone in the industry who pointed me in the right direction.” Andy (22) As someone who is unemployed with very little work experience, I need a tool to help me actively develop my skills and gain experience, so that I have a greater chance of landing that first job. Interviewees who were graduates (of all ages) were receiving rejections on the basis that they had “no relevant experience” for the position. This is also pertinent for school leavers and those wishing to make big career changes. “The one thing you lack as a graduate is hours worked in the relevant profession, work experience. That is a gap that needs to be bridged because people keep telling you that is the thing you need.” Henk (30s)
  24. 24. KEY INSIGHTS Unemployment is often confidence sapping, uncertain and stressful. Feelings of self-worth and successful employment are intrinsically linked. We place a great deal of importance on what we do in life, on what we are good at. Without purpose, without feeling useful, people tend to struggle. “You just, kind of, fall into a black hole. I was struggling to find the energy to look for jobs. All I wanted to do was stay in my bed, watch TV and kind of, not even leave my house and, yes, it was really hard.... I’d start drinking at two o’clock in the afternoon. Not that I was becoming an alcoholic, but I just – yes, I kind of, it was hard for me to push myself really and go out there and really try to find a new job.” Lesley (29) When looking for employment, people can also neglect all the positive activities they usually do to keep themselves well. There is a lack of normal working routine, with no ‘time off’. This steady erosion of self-esteem and confidence triggers a vicious cycle: the lower your self-esteem, the more difficult it is to present yourself, and to identify and feel positive about your own skills and abilities; and thereby the more difficult it becomes to gain employment. “I was only looking for jobs at the time, so I felt like I needed to get something because I wasn’t going back to my country. But I felt like it was my only goal at the time so I wasn’t really enjoying life at that moment… Yes. I wasn’t sleeping very well. I think it was the most stressful situation in my life.” Carl (27) For unemployed people it’s particularly important that online services connect to offline ones. Many interviewees talked about the value of offline interactions in building their confidence and motivating them. “I suppose since I’ve been with them [a mental health employment support group] I’ve got a bit of bounce more in my stride, in my step. I’ve got a bit more confidence with myself and that’s the main key, being confident. I’m going to places and I don’t know, I suppose it’s very helpful.” Derek (37) “I never felt any real help until the lady [Jobcentre Advisor] at the time sent me on my course and that was probably the best course I ever went on.” It was a turning point in my life. … it involved building up a CV and interview skills, interview techniques, we did all that, gaining confidence in looking for employment and working alongside FINDING WORK / KEY INSIGHTS
  25. 25. other people. It’s a few years ago now. Team building skills, we did quite a few team building skills. … ” Ted (53) “She was very supportive and when you’re in a situation like that you tend to feel you’re not good enough, or you start saying bad things to yourself all the time. But she was very supportive. She said, “You’re kind of young and you’ve worked with really good companies, so I don’t see any problems here for you to get a job quickly.” And it was the case; she was right.” Carl (27) It is vital for people with mental health issues to understand the working conditions that will help them thrive. All too often, people with mental health issues find themselves in work environments that trigger mental health issues, rather than support mental wellbeing. “It was a very fast paced bar and with my anxiety and other mental health problems it was a real struggle, especially as I’ve got quite a lot of visible self-harm scars. It was very difficult for me to come out, to be able to have sleeves rolled up at all. So I usually didn’t. I needed quite a lot of breaks because I was getting overwhelmed. So I ended up leaving that after about three months.” Katy (24) This can be a real issue for those under pressure to seek work via the Jobcentre where the focus is often to get them into any employment rather than to find work suited to their mental health condition. “... if they said to me, “You have just got to get a job” and then tried to force me into the bacon factory or something like that, I would have ended up back where I was, if not worse. Let’s face it, I was suicidal enough as it was when I was ill. It probably would have ended up that way.” Charles (45) Volunteering for mental health organisations often plays a valuable role in moving people with mental health issues into work and helping them better manage their psychological wellbeing. Volunteering allows people with mental health issues to gain many of the benefits of work (feeling valued, moving away from isolation into sociable situations, building a sense of routine and purpose) without the pressure of normal employment, in a supportive, flexible, environment, surrounded by people that understand their mental health issues. “I think having had mental health problems, working in mental health is – there’s a kind of comfort to it, and I think when you’re surrounded by people who’ve had
  26. 26. FINDING WORK / KEY INSIGHTS mental health problems…there is a sense of comfort being able to come in and say, “I’m having a really bad day,” or knowing that if you’ve had a bad day, someone is going to text you at 8:00 to see how you’re doing, and vice versa.” Sandra (36) “I think I was always a notorious quitter when things got bad with my health and stuff like that; I would drop out of things. So Young Minds is probably the thing I’ve stuck with the longest but that’s because it’s had such a positive influence on me.” Kate (24) Helping others with similar problems can boost one’s own wellbeing, and give sense of purpose and value. “It makes me feel wanted and needed, which I know I am, I know I’m there. They do rely on me sometimes.” Ted (53) Volunteering for mental health organisations also enables people to build skills and confidence as well as to learn more about managing mental health conditions. “I’ve done mental health training. That was excellent, taught me a lot. … listening to people as well and people’s experiences. I find that a very good way of learning about mental health and without actually having to read about things.” Ted (53) However, the nature of working within the mental health sector can also be problematic, as some interviewees described. There is the danger of burnout in the face of working with people in highly emotional and distressing situations. There is also the risk of emotional triggers. It is important that unemployed people can build a wide social support network with employment in mind. Building a wide social and professional network has distinct advantages for people seeking work. Knowing the right people particularly in the relevant sector was deemed a clear and important route to finding work opportunities, getting a foot in the door, and receiving valuable advice. Peer-to-peer support from others in similar situations was also described as invaluable in boosting self-esteem and providing advice. However, building an effective support network is not easy. Interviewees described networking events as intimidating. It can also be hard to reach out to strangers to ask for advice, if people are already suffering from low self-esteem due to a long and unsuccessful job search.
  27. 27. CASE STUDY RAJESH Rajesh is a 25 year old volunteer recovering from a phase of mental ill health and working to transition into full time employment. He currently lives in South London with his father and his three cats, but will need to move out soon because his father can no longer afford to pay the mortgage and needs to downsize. He had a difficult childhood of bullying and social isolation, and his parents had a difficult relationship partially due to his father’s alcoholism. His depression and anxiety pushed him to leave formal education for 5 years between ages 13-18, meaning that he had gained his GCSEs much later at age 20. “I was severely depressed because of severe isolation.” Rajesh is currently volunteering with a number of mental health organisations where he used to receive formal support: he now leads a badminton group once a week, and he is volunteering in an admin role in the office of a mental health charity. He has just applied to LINK, a transition to employment service from the NHS that allows Rajesh to do up to 10 hours of paid work a week, whilst still claiming benefits. Rajesh is on track to start full time employment, but he is also vulnerable and needs support if he is not to fall off course. “...before my mum died, last year, I was starting to look for work, full-time employment, as well. By then, I was ready, but obviously, after my mum passed away, I had that setback.”
  28. 28. FINDING WORK / CASE STUDY USE OF DIGITAL Rajesh has wifi at home and uses his tablet on average three hours a day, spending most of that time watching videos on YouTube, and searching for information and advice about managing his anxiety and loneliness better. “Having the visual, audio content is easier than just written or – rather than just written, or small video clips, having longer, mainstream videos, or audio, even, would be helpful.” He also is on Facebook, but is a passive user, and tends not to reach out to others through posts, but rather reads and hears of others activities. For work related tasks, he tends to use a laptop: searching for jobs, updating his CV and writing applications.
  29. 29. This diagram illustrates who Rajesh goes to for support. His support network is mapped in terms of levels of trust and frequency of use. RAJESH’S SUPPORT NETWORK
  30. 30. Most used Least used Most trusted Least trusted Point of contact: Online Phone Face to Face Other Kind of support: Work related Mental health related Both Icon by Jens Tarning from the Noun Project Orchard House Employment service at Mind Active Minds Badminton Social Networking service at Mind Psychiatrist Porch Light LINK (yet to start, part time work) (Mental Health Service) (Housing Support)
  31. 31. High Low EMOTIONAL TIMELINE MENTAL HEALTH & WELLBEING Taken out of formal education to be homeschooled for 5 years. At private academy no friends, poor results, becomes suicidal. Aged 12 diagnosed with depression after bullying at school and difficult home. 4 months under observation in hostpital improves through support. Discharged to a mental health team in community. He doesn’t like his Dr or team, who blame his problems on his parents and don’t offer much support to change his situation. Put into private academy to continue education. EMPLOYMENT / EDUCATION This diagram highlights key points in Rajesh’s life in relation to developments in his mental health and career. They are plotted against his relative sense of wellbeing. RAJESH’S EMOTIONAL JOURNEY
  32. 32. Rajesh re starts school, enters college to gain GCSEs. Applied for a part time paid position, is on positive trajectory toward employmet. Volunteering for community mental health to gain skills and build resilience networks. Must become indepedent quickly, financial pressure in family home. Mum passes away, Rajesh plummets into depression. Feeling strong, joins mental health charity groups and sports great for mental health. Aged 18, sectioned, 2 months in hospital, range of support for the first time.
  33. 33. Lorna is in her fifties, mother to two grown sons. She is currently seeking employment and volunteering part time for a mental health charity. She lives with her youngest son in a seaside town on the North West coast of England. After leaving school, Lorna took up a job in a local factory as a seamstress, which she enjoyed. During that time she got married, bought a house with her husband and became pregnant with her first son. She left her job to care for him and had a second child a few years later. She loved being a full time mother and has not returned to work since. WIth her sons in her teenage years, Lorna got divorced, but was happy in a new relationship that saw her move abroad. However, she began to suffer from depression after a series of traumatic events. Both her parents became ill and Lorna returned to the UK to care for them, but they subsequently died. Following this, she experienced a very painful break up with her long term boyfriend. She sees her GP infrequently to receive anti-depressants. She is currently on JSA and faces real challenges in her search for work, not having been in employment since her children were born. She finds the job hunt extremely demoralising as a result, but really enjoys volunteering part time for a mental health charity, working in the shop and supporting those with mental illness to carry out practical tasks. She is a natural helper, spending most of her free time supporting friends and family (when she is not restoring antique furniture; her favourite past time. CASE STUDY LORNA
  34. 34. FINDING WORK / CASE STUDY USE OF DIGITAL Lorna has both a laptop and tablet at home and access to the internet. She mainly uses her tablet for online window shopping and to access Facebook, both of which are currently causing her some distress; she cannot afford to shop, living on JSA as she is, and social media updates from her ex-boyfriend can send her into low moods. She uses her laptop in order to search and apply for jobs. However, she struggles to use programmes such as Word, and receives help from the JobCentre in order to create CVs and fill out application forms. Her youngest son sometimes helps her with technical computer issues, but he is himself currently seeking work and struggling with what she suspects is depression. As a result, he can sometimes be unresponsive and unwilling to help.
  35. 35. This diagram illustrates who Lorna goes to for support. Her support network is mapped in terms of levels of trust and frequency of use. LORNA’S SUPPORT NETWORK
  36. 36. Most used Least used Most trusted Least trusted Point of contact: Online Phone Face to Face Other Kind of support: Work related Mental health related Both Icon by Jens Tarning from the Noun Project Cousin Community at Mental Health Charity GP Best Friend Job Centre Friend
  37. 37. High Low EMOTIONAL TIMELINE MENTAL HEALTH & WELLBEING EMPLOYMENT / EDUCATION Secured a job as a seamstress straight from school and enjoyed the work. Dip in wellbeing after divorceBirth of sons Left work to care full time for children.
  38. 38. Finds happiness in new relationship and moves abroad Returns to UK to care for parents Death of both parents in quick succession. Began to seek work for the first time. Struggling with a limited CV and finding the search demoralising. Began to volunteer for mental health charity and feels useful. Difficult break up with partner. LORNA’S EMOTIONAL JOURNEY
  40. 40. Being in and out of work covers many different types of work, from freelancing, to temping, to interning to zero-hour contracts. Financial uncertainty is a key stressor for this group. In addition to the intrinsic anxiety this brings, it also means that people find it hard to turn down jobs when they come, which can lead to overwork and stress. Freelancers can find it hard to manage their work/ life balance as there are no clear ‘office hours’. Isolation is a challenge for many people who are in and out of work. It’s much harder for people in this group to find mentors and many don’t have managers or colleagues to go to for advice. This isolation is compounded if people work from home. The emotional and financial pressures on freelancers can make it hard for them to plan their career strategically, invest in their career development and acquire new skills. People in insecure employment will sometimes find themselves at multiple stages of the employment matrix simultaneously, looking for new work at the same time as delivering existing work. SUMMARY
  41. 41. IN AND OUT OF WORK / USER NEEDS USER NEEDS MANAGING WORK/LIFE BALANCE As a freelancer who is the primary breadwinner in my family, I work a lot of hours, most evenings and weekends. I need to help/reminders to help me better manage my work/ life balance. Financial uncertainty means that freelancers often feel pressure to take all work that they are offered, even if it means working long hours. “It’s funny, I’ve been working weekends for as long as I can remember it seems. Just something to help me gain – we didn’t talk about mindfulness at all, but I don’t even feel like I have time for meditation at the moment, but something that would help me focus and reflect more, I think would be helpful, take me outside that bubble.” Julie, (36) Sociable hobbies, local communities of interest and regular activities can help counter the lack of structure in the working life of those in insecure employment.
  42. 42. CONNECTING WITH OTHERS AND BUILDING NETWORKS As a freelancer who has just relocated, I need help to meet new people and places so that I am less isolated and can build new personal and professional networks. When freelancers relocate, many find themselves even more isolated as they don’t have colleagues or local networks of other freelancers. “I work mainly at home. In terms of network, that has taken me a really long time to build up. I do have friends now, but they all live outside of town mainly. I’ve got two friends in town. It took four or five years to actually make any friends.” Julie (36) As someone who often works alone, I need something/someone to reach out to me and give me a boost so that when I feel down, I don’t isolate myself further and sink further down. Isolation is a key challenge for the self-employed and can exacerbate mental health issues. “I was just finding it all pretty tricky… I’d sometimes work for a company, but can be working solitary at my desk in my flat for an entire week, if they didn’t need me in the studios. So he [flatmate] was coming home to a flatmate that hadn’t spoken to anyone all day. So you’d either just be wanting to chew his ear off about anything, just talk, talk, talk, talk or be in a pretty desperate test where you just want to rant about things.” Gary (29) “There were many times I could’ve reached out for support but didn’t [because I didn’t feel strong enough]” Vinny (35) describing times when she worked alone and struggled to reach out. As a freelancer I need access to mentors so that I can build my confidence and benefit from others’ experience. “I think for too long I’ve worked as a designer without a senior. Through the freelance game, whenever I was on a project, the designer with most responsibility was me, so there was a lot of, I guess, learning on the job, which is excellent. You have to learn quickly, but it has meant my confidence at work has never been maybe as strong as it could be because I don’t have the – I’ve not had the mentor behind me to make me feel that that is the right decision.” Gary (29)
  43. 43. IN AND OUT OF WORK / USER NEEDS GIVE EMOTIONAL AND PROFESSIONAL SUPPORT As someone juggling multiple jobs and caring roles, I need a decision-making tool to help me think through options in a logical, methodical way so that I don’t make snap decisions without thinking when I am stressed out and time poor. The emotional and financial pressures on people in insecure employment can make it hard for them to structure their working life in a methodical way. With no boss or colleagues to go to for advice, freelancers can find themselves having to make difficult decisions under pressure without support. “I use project management apps a lot and they are very much about planning the future, but I wonder if there’s something that could do that in a personal way as well, how do you plan the different elements of your life, so work, family, other stuff. Work out what you want from your life. It could almost help with decision making I suppose, because decision making is quite stressful.” Julie, (36) As someone transitioning into full time employment, I need a heads up about the challenges that will come with working in a team again so that I can assess the pros and cons of freelance vs. employment and have a cleaner transition. Although moving into full time employment from insecure employment can be a welcome change, it also comes with a new set of challenges. “Yes, I switched from freelance to an employee just two and a half months ago. So it’s quite different. The transition has been testing at times. Over the last couple of years…I have worked for different clients in different parts of London, different desks and different projects, but in the last couple of months it’s been all the same projects, all the same people. That comes with its own challenges.” Gary (29) “But what fascinated me is the topic of freelancing & self employment had rarely been discussed (at University). There are students who are willing to choose the role of a freelancer but have very little knowledge of what to expect (e.g. self discipline, loneliness, handling invoicing, seeking clients) I really feel this is a topic that needs be discussed in university.” Andy (22)
  44. 44. PLAN THE FUTURE As a temp/short-contract worker, I need to find ways to plan the future, so that I don’t feel so unstable. People in insecure employment need help planning at least some aspects of their future to give them a sense of direction and help with the inherent uncertainty of their situation. “You feel unappreciated, bottom of the pile. Non-permanent, zero hours equals job insecurity” Visha (32) “I find it hard to look for another job as I’m lacking in motivation due to the changing hours.” Amy (25)
  45. 45. KEY INSIGHTS The financial uncertainty common to those in insecure employment can be detrimental to mental wellbeing This employment stage is characterised by financial insecurity for many. Financial pressures can lead freelancers to take on too much work, but to also feel like they never have a break, as time in between jobs they are looking for work and anxious about money. “Some of it’s financial. It’s like, “How are we going to pay the bills?” That’s a fairly obvious one that most people feel most of the time I think when you’re working for yourself.” Alex (58) “[In response to ‘Did you ever get stressed about money in between temp jobs?’] “Yes, I did. Yes, I did. Mum would always kind of help me out if I needed to – which in a way, is a bad thing, if you have a thing to rely on; you can get a kind of crutch of functioning that way, rather than anything else.” Jerry (33) “[on other clients in insecure employment] Being realistic, if their finances go out the window, that’s very likely to provoke a decline in mental health, as well, so it’s really a balancing act for everybody.” Jerry (33) Many are put off from attempting to seek benefits, allowances and financial support even if they are earning below minimum wage on average. The system was deemed too difficult to navigate and not flexible enough to accommodate more complex and changing work situations. Isolation is a key challenge for the self-employed. “When you’re trying to get something off the ground which is your own venture, if it’s just you, you’re reliant on yourself not just to have the idea and to develop it but to do your own marketing, to go out and engage the world and all of that, and then go and deliver the thing and then do the invoices. You have to do it all. That can feel quite isolating” Alex (58) “But I was struggling with the freelance nature of it and I was struggling that I wasn’t – because I was working freelance and I wasn’t getting to know a group of people in an actual work environment and making friends and going for Friday night drinks, I was feeling very alone.” Gary (29) New parenthood can be a particularly difficult time for self-employed people. IN AND OUT OF WORK / KEY INSIGHTS
  46. 46. When self-employed people become parents they often face a challenging time managing caring responsibilities, maintaining their networks and entering back into the job market. “It was about three and a half years after I went freelance I had my first child. I initially gave up work for a bit, but I regretted doing that. It was very, very hard to build up my work again afterwards. Then we had financial difficulties as well.” Julie (36) Many graduates find themselves in insecure employment. New graduates can face difficult times, dealing with the tension between wanting to find fulfilling work that makes make the best use of their skills and realises their ambitions, and the reality of having to take any job available just to survive. Many interviewees felt that university did not adequately prepare them for this. “I’m a really firm believer, and still am now with all the students here that university doesn’t prepare you for the year after you graduate There was no coaching into that or some sort of transition. It really did feel like the strings were cut. Working three part-time jobs, trying to get by in what I knew I wanted to do…dear God, it was pretty depressing.” Sonia (28) “It was just a really difficult catch-22. Too tired to look for any other work. I thought, well, if I get any other work, I can’t really do it because I can’t just take time off. So actually this was a really bad decision but I’m stuck in it.” Usha (37) “After my PhD I was quite clueless and paralysed in some sort of limbo.” Sam (34) Lack of sick leave is a key challenge for freelancers with mental health concerns. Those in insecure employment are particularly vulnerable when it comes to taking time out because of mental health issues. People will often keep going for as long as possible. “It was a difficult time. but I needed to go to work because I was freelance, I didn’t get any sick leave. Oh yes, with all of this, I’m freelancing; I’m not entitled to sick pay so…I was working, basically, for the same company throughout. It was contracts of six weeks, and then another six weeks.” Vinny (35) “It’s just the fact that it could end at any time and not being able to take time off. I went into work with a broken arm, to give you an example.” Vinny (35)
  47. 47. Temporary or freelance work can be beneficial for people with mental health or physical issues. Insecure employment can provide a greater level of flexibility and choice, which can be helpful for those managing ill health. “One of the issues I was having around that time was I was diagnosed with Crohn’s Disease, and actually working for a temp agency was quite good, because I could say to them, “Look, I can’t work anywhere that I’ve got to be there before 10:30 in the morning” That, perhaps, is more difficult when you’re looking for a normal job.” (Stella, 36) For some benefits of the flexibility of insecure work offset the negatives of uncertainty: “It [working in the voluntary sector] is more flexible, and I think they have to be, because you’re constantly working on a short-term contract, it’s really un-secure work. I know that I’m funded until April next year, and then that might be the end of it, and that could change in a month’s time. I think they have to, where possible, counteract that with a flexible working policy.” (Stella, 36) Seasonal work can be useful for some as it combines security (i.e. the knowledge that the work is always available at certain times of the year) with a finite amount of work. This can be beneficial for some with mental health difficulties who struggle to manage full-time employment. “I used to do some temporary work at a local seed company in U_____, working through the winter. That’s the only work I did in that time. … It was quite manageable…because it was only three months and I knew there was an end to it, which I needed.” (Ted, 50-55) Unpaid internships can cause people to de-value their own work and place them in difficult financial situations. Interviewees spoke of the problem of unpaid internships setting a negative precedent at the beginning of their careers. “It is easy to lose a sense of the value of your own work and to not expect pay that matches your experience.” Andy (22) This doesn’t only have a financial impact, but a more fundamental effect on feelings of self worth. IN AND OUT OF WORK / KEY INSIGHTS
  48. 48. Interviewees also pointed out that many employers do not seem to have the capabilities to help develop their interns effectively. “I have worked for a few companies that, quite honestly, haven’t even the vaguest notion of keeping any interns on board. But you are told you need to do an internship in order to get your foot in the door. But the chances are you are never going to get close to actual design, you are just going to do the things that no one else wants to do.” Henk (36)
  49. 49. CASE STUDY GARY Gary is 29 year old guy from a small village in Scotland. When Gary graduated from a degree in product design, he did a few internships, and then worked as an employee for an international firm for a short time. He was made redundant when the recession set in. He decided to use it as an opportunity to go travelling, and to search for jobs for his skill set elsewhere. He was unable to find work anywhere he went, and so ended up working “backpacker jobs”: restaurants, bars and farms. Returning to the UK after two years, Gary felt pressure to get on with his career and get back to working within his field. Without clear job prospects beyond bars and restaurants, he applied to do a Masters in design, but was rejected. This was a big set-back. Eventually Gary picked up the pieces and decided to move down to London, but he didn’t settle in well. He lived in a very busy part of town and was stressed out by the number of people around him contrasted to the loneliness and isolation he felt working on his own, the constant pressure to seek and deliver work, and financial difficulty of paying rent in the capital. “But London was just terrifyingly overwhelming at all times for the first 18 months, partly because I was coming down here on my own looking for work... For the first 2½ years I was freelancing, so looking for work every day, every week making sure I could pay that frightening rent.” He also felt unsupported professionally. “...throughout my career in design I’ve felt like maybe I’ve needed a design mentor. Someone, a creative director with loads of years of experience that would help me manage situations in a most efficient and best way possible, I’ve not had the mentor behind me to make me feel that that is the right decision.” Over this time Gary persevered with a combination of internships and freelancing for different design firms. He recently switched from freelance to a senior management role. The transition has been testing at times… “I have worked for different clients in different parts of London, different desks and different projects, but in the last couple of months it’s been all the same projects, all the same people. That comes with its own challenges.”
  50. 50. IN AND OUT OF WORK / CASE STUDY USE OF DIGITAL Gary is a keen user of digital. He has Wi-Fi and uses his laptop between 8-10 hours a day, mostly for work (design programmes, emails), but also for watching TV and video (Netflix, ITunes), reading the news, and shopping. He is an active social media user, particularly with Instagram where he likes to post pictures, but uses Facebook much more passively, to browse and mostly kill time when he is bored. He uses apps like Strava to find cycling routes and track his fitness.
  51. 51. This diagram illustrates who Gary goes to for support. His support network is mapped in terms of levels of trust and frequency of use. GARY’S SUPPORT NETWORK
  52. 52. Most used Least used Most trusted Least trusted Point of contact: Online Phone Face to Face Other Kind of support: Work related Mental health related Both Icon by Jens Tarning from the Noun Project Gym Long Distance Friends Local Friends Girl Friend Team sports Himself Mum Music (spotify)
  53. 53. High Low EMOTIONAL TIMELINE MENTAL HEALTH & WELLBEING EMPLOYMENT / EDUCATION Moving away from home to attend Uni. Working unpaid internships. After working for an internaitonal firm he was made reduntant, with no support to find a new job. Keen user of digital for fitness and socialising. This diagram highlights key points in Gary life in relation to developments in his mental health and career. They are plotted against his relative sense of wellbeing. GARY’S EMOTIONAL JOURNEY
  54. 54. Travelling and working in temporary, low skilled jobs. Not getting into Master’s, establishing himself in London. Moving from freelance to senior management team of design firm. Struggling to transition, little support. Stressful as this was a big setback. Under financial pressures. Isolation. Throughout career felt he needed a mentor, finally had people.
  55. 55. Julie is 36 year-old mother of two young children. She has been freelancing for the past nine years, as well as looking after her children for the past 5, and she is currently in transition back to full time work. She is switching roles with her husband, who will be taking on the full time care of their two young children. Julie and her husband both have creative jobs, although Julie increasingly took on project management and organisational roles to bring in more money as her husband’s business began to struggle. The birth of her first child was traumatic with Julie nearly dying in childbirth. She stopped working after the birth to recover and take on the caring role, and this put further financial pressure on her family, pushing them to move out of London into rural England. As a result, she lost her social network and also her relationship was heavily impacted by her near death experience. She started struggling with anxiety, depression and loneliness, and five years later is just working her way out of that. “In terms of network, that has taken me a really long time to build up and social network there. I do have friends now, but they all live outside of town mainly. I’ve got two friends in town, but I have other friends who are in towns nearby. It took four or five years to actually make any friends.” Julie is now working freelance projects all the time and is very busy and time poor. Her business and work-related stress makes it difficult for her to keep perspective on things; she gets caught up in work related problems, and struggles to relax, and to get to sleep at night. “It’s funny, I’ve been working weekends for as long as I can remember it seems.” CASE STUDY JULIE
  56. 56. IN AND OUT OF WORK / CASE STUDY USE OF DIGITAL Julie uses technology a lot, and has Wi-Fi at home where she works, spending 12 hours plus a day on her laptop which is reserved purely for work. She is also constantly on her mobile phone, using it for phone calls, primarily to her sister in law and mother in law with whom she is very close, but also for checking emails on the go, calendar management, work tools like LinkedIn, twitter and news sites. Solitaire is her go to app when she can’t sleep, as well as Spotify for listening to music. Back when she made time for walking, she used Breathe to track her activity, steps, and calories lost. She is a passive user of social media, and generally finds going online to be bad for her wellbeing.
  57. 57. This diagram illustrates who Julie’s goes to for support. Her support network is mapped in terms of levels of trust and frequency of use. JULIE’S SUPPORT NETWORK
  58. 58. Most used Least used Most trusted Least trusted Point of contact: Online Phone Face to Face Other Kind of support: Work related Mental health related Both Icon by Jens Tarning from the Noun Project Online (reacts badly to this) Walking Colleagues Friends `In-laws Counselling
  59. 59. High Low EMOTIONAL TIMELINE MENTAL HEALTH & WELLBEING EMPLOYMENT / EDUCATION At University Julie didn’t make friends easily felt isolated. Uni had good art resources, important source of stress relief for Julie. Depressed drank and smoked to cope. GP put her on antidepressants (didn’t help) referred her to counseller (did help) Julie moved to London and started a job that she loved; supported by manager.
  60. 60. Working as freelancer for money. Planning to go back to working full time. In London, she developed strong network,lived with best friend, met future partner First child traumatic birth. Partner struggled to cope. Mental wellbeing was cared for by midwives but after birth support ended. Financial struggle, child care full time, partners company struggling. Move to Hampshire to cut costs. Loses network - hard. Juggling freelance and caring is hard planning on swapping with partner. JULIE'S EMOTIONAL JOURNEY
  62. 62. Interviewees in full time employment described how they needed support to help them manage stress at work, to deal with difficult working relationships, to progress in their career and to deal with new responsibilities that come with promotion. Workplaces can be unsupportive when it comes to mental wellbeing. Some interviewees described how they felt it was safer to hide their mental health issues from employers either because of fear of discrimination or stigma. Open and supportive working environments can be transformative for people with mental health issues. Managers are a key touchpoint here, playing a vital role in fostering the wellbeing of their employees, helping them manage their workload, develop positive attitudes, and where necessary take time out. Yet managers often lack the resources to recognise mental health issues and support employees. It can be difficult for people who are in full time employment to access mental health services either because of logistics of because of perceived need. SUMMARY
  63. 63. MANAGING WORK / USER NEEDS USER NEEDS HELPING PEOPLE MANAGE WORK STRESSES, DIFFICULT PROFESSIONAL RELATIONSHIPS AND PROMOTION As an employee who is feeling stressed/low, I need a way to indicate that I don’t feel 100% without having to have an explicit conversation about it. It is important for people with mental wellbeing issues to be able to indicate when they are having a difficult time. This enables them to receive appropriate support and ultimately to stay in work. “My human resources manager knows about my mental health stuff and she said at the beginning, “Just keep us updated”. Now I feel like if I am really struggling, I don’t have to phone in and pretend, “Oh I’ve got a cold, I feel sick, I’ve been sick all night”. It’s just, “I’m really struggling with my mood”. That’s really nice to be able to know that I’ve got that support.” Debbie (22) “I just had to throw the towel in and go off on the sick over Christmas. The new line manager just made me feel stupid when I’d been working the job for 20 years. She’s making everyone feel depressed. When I go back, I need a constructive way to talk to her but it’s nerve wracking, no one knows how to approach her.” Andy (48) As someone who experiences a lot of stress at work, I need tools that will help me monitor my mental wellbeing and give me useful advice about how to self-manage, so that I can thrive in my job. Employees need to be supported to develop self-awareness and self-management strategies that allow them to work in the best way possible. “I had a period of two terms off with I don’t think they called it stress, I don’t know what it was. I went back and it was very uncomfortable. I knew that my mental health wouldn’t take, I couldn’t go back to college. I had a major meltdown.” “I’m a born worrier, born with anxiety complexes and guilt. In the end you make a decision, don’t you? You either say, “I’m really ill,” or you just go, “It’s part of me.” It’s only part of me and so I just get on with it.” “(Since then) I’ve never been as profoundly ill. Well, what I’ve learnt from that experience is I now know my signs and symptoms and triggers so I take better care of myself. I also read quite extensively and I do a bit of yoga. I know when I’m getting to my stress points.” Susan (60)
  64. 64. As an employee with a difficult boss, I need tools that will help me manage the situation, so that I can stay in my job. Relationships with bosses can be a key stressor at work. People are often confused and disempowered when it comes to addressing problems with managers. “I’d say it got pretty rubbish then because the person I was working under was massively incompetent. She did end up getting sacked and then that’s when I became the manager but it was my first experience of working under somebody who just couldn’t deal with the job and I didn’t know how to deal with that. Who do you turn to? Is it an HR thing? Do I go above them to their boss? I guess it was quite rubbish.” Sonia (28) As an employee who has just been promoted, I need tools that will help me manage new responsibilities and stress. Promotion can be a very stressful time: pressure increases, people feel less able to ask for help for fear of looking like they aren’t coping and can experience self-doubt. “So I was kind of thrown into the deep end, I had massive events with, like, 1,000 people, no help, no support at first. I was running around, my feet were literally bleeding, it was very stressful at first.” Lesley (29) As an employee with mental health issues, I need a tool that will help me find appropriate face-to-face support outside of working hours, so that I don’t have to take time off to get help. It can be difficult for people in full time employment to access mental health support because of logistics, with most support being provided during office hours. Another problem is that they can be judged as less deserving of support, because of the assumption that the fact they are still working shows they are coping. “There was no way that I could work full-time and commute four hours a day and access their services because they were nine to five.” Kate (24) “I did used to go to a nurse-led clinic, but because I worked, the nurses weren’t that interested. They used to say, “Oh, well, if you’re good enough to go to work, you’ll be alright. You’ll get over it,” and I never got on with them at all.” Mandy (47)
  65. 65. MANAGING WORK / USER NEEDS SUPPORTING LINE-MANAGERS TO FOSTER POSITIVE MENTAL WELLBEING AMONG THEIR STAFF As a line manager, I need tools to recognise my employees’ mental well-being so that I can support them before they reach crisis points. Line-managers play a vital role in fostering the wellbeing of their employees, helping them manage their workload, develop positive attitudes and, where necessary, take time out. “Carol is an amazing line manager, she’s very accessible, she doesn’t question. There’s no value judgment if you say, “I’m absolutely at my beam end, I’m not going out again today.” She’ll say, “Yes, that’s absolutely fine.” She monitors, she reassures that you’re actually meeting your work targets and you work loads, you’re not freeloading, so she makes sure you feel comfortable with saying, “I need some time out for an hour or two,” makes you feel safe I think.” Susan (60) Yet many line-managers are often unaware of how they can support workers with mental health issues. “It’s a problem that I think a small organisation will always have; we’re not HR specialists. We don’t have an HR department. Our HR is only as good as what [colleagues name] and I can keep up with. We can ring ACAS for advice on things, but you have to know when to ask for advice, and sometimes we’ll get it wrong.” Stella (36)
  66. 66. ENABLING PEOPLE TO PLAN THEIR NEXT CAREER STEPS As someone who feels low and stuck in their job, I need tools that will help me develop more awareness of my current levels of fulfillment and understand how to develop my career, so that I feel like I am moving forward. Sometimes people find themselves stuck in unfulfilling work where they aren’t using their skills or realising their potential. This can be frustrating and disheartening. “The work … It was too repetitive. I don’t know, I think some people can do that, because all they can think of is the money at the end of the week, but when you have got a mind that just will not shut off, you can’t do that. You just can’t do that sort of thing.” Charles (45) “Although I do really love my job here, there isn’t much chance to be creative or have an outlet for that kind of thing...She [the careers coach] just helped me see what I wanted to do, which is writing, but doing it as a side line.” Carrie (40)
  67. 67. MANAGING WORK / USER NEEDS HELPING PEOPLE UNDERSTAND AND ENFORCE THEIR RIGHTS As an employee who faces discrimination in the workplace because of my mental health, I need a tool that helps me find out about and assert my rights. Some interviewees described the hostility and discrimination they faced at work. In these cases people need information and support to be able to assert their rights “I think I was signed off work for two weeks, and they asked me to resign, because they said, “Well, the shop can’t be closed”. At this time I was quite poorly, so they kind of pressured me to resign. … in the end I said, “Look, if you want to fire me, you fire me, but I’m not resigning,” so they just said, “Well, don’t come back to work,” and then I got a letter saying, “Thank you for your resignation, by the way, you owe us £200 because of holiday you’ve taken that hasn’t been accrued, ...” Stella (36)
  68. 68. KEY INSIGHTS Often people feel it is safer to hide their mental health issues from employers. Interviewees spoke of hiding their mental health issues from employers out of fear of stigma or discrimination. “It’s ironic, really. I work in HR, and yet I wouldn’t say anything to work. Yes, I’m not really keen on telling them. I tell them as little as I can, and I don’t believe that it stays where it should.” Karen (42) Yet all too often, keeping mental health issues from employers can ultimately result in loss of work. Take the case of David who became depressed when negative work relationships at a warehouse he worked in brought back memories of school-bullying. After numerous instances of being signed off work, David was made redundant. He never felt he could speak to his line manager about bullying in the workplace, or about his resulting depression. Or take the example of Roz, who resigned rather than inform her employer of her mental health issues. “I did go to work at a chemist…but I left there because I started to feel like a breakdown was coming on. I found out afterwards, the pharmacist was so nice and understanding he said, “You should have told me and we would have let you have time off.” But I gave the job up because I thought, “I’m making mistakes in the till. I can’t be doing it.” I didn’t think that I could have had help and support and time off at the time. I wasn’t in the right frame of mind to think that.” Ruth (54) The workplace can be a very unsupportive environment for people with mental health needs. Some interviewees faced discrimination and bullying in the workplace because of their mental health issues. “So they constantly go on about my depression and my illness, and they don’t let it go. And they cause most of it by how they treat me. We change managers roughly every two to three years in the store I work in, and if you get a nice manager, you get a good three years. If you get a horrible manager, you’ve got a bad three years. They asked me what tablets I’m on, and I refused to tell them. They say I haven’t got depression. I’ve been told I should give my job up. I was also told once, by a manager, “We don’t keep shit in this store, so you’d better leave.” Mandy (47)
  69. 69. “ So every time I go to work, it’s in my head, “Is it going to be today they start?” Because even though I’ve won all these cases, it doesn’t stop them; they still carry on. I don’t want to change my job, because my hours suit me, and it’s five minutes up the road. I think, “Why can’t they just leave me alone? It’s never ending.” Mandy (47) “If someone is off with broken arms and legs, people rally round them. If someone is off with mental health problems, they are like, “Oh. They will pull themselves together sort of thing.” That is what I think they miss. A lot of places need a lot of training to understand it a little bit more.” (Charles, 45) Open and supportive work environments can be transformative for people’s mental wellbeing. Interviewees described the relief of finding a work environment where they could be honest about their mental health issues. “It was freedom… The most important thing was that I could actually be open about my mental health. I think that’s the thing that made the biggest difference, that I was no longer calling saying that, “I had a migraine.” Kate (24) “My boss was really understanding. She said that she’d gone through similar feelings of anxiety before, a perfect storm of life events all happening at once. I just had a lot of people around me who were very supportive.” Sam (28) Line-managers are crucial touchpoints. Line-managers play a vital role in fostering the wellbeing of their employees, helping them manage their workload, develop positive attitudes and where necessary take time out. “So I started working with a major client. My God they were so stressful, the demands, the wishes, the kind of projects, everything kept coming, kept coming, kept coming and it was really difficult to cope with that, as well as everything else, all my other clients, and everything else anyway. So that was really stressful and I talked to my boss about it and we looked at different ways of making it easier..” Carrie (40) “No (not official counselling), it was just support, having good managers really, supervision….Yes, they just took time, supervisions were regular, I think that was really important. They took time to listen which I think was a key thing.” Sharon (39) “Quite often in this sort of work it’s colleagues who first notice that you’re having a wobble. They’re quite astute, it’s like an early warning system, sometimes they pick it up before family MANAGING WORK / KEY INSIGHTS
  70. 70. do because, I suppose, of your body language or that you’re just not yourself in some imperceptible way that you perhaps haven’t yet noticed.” Susan (60) Lack of job fulfilment can trigger mental health issues. Sometimes people take jobs due to immediate financial necessity, rather than to meet longer term career goals. Some interviewees described how damaging it was to their mental wellbeing to work in a job that they disliked, which didn’t use their skills and experience. “… ended up doing the most horrible disgusting horrible job on earth, which was at the bacon factory … It was horrible. I think that is probably what sent me downhill more than anything in my life. I still shudder thinking about it now ... that was the most demeaning thing I’ve ever done in my life. It was horrible.” (Charles, 45) “All these..., for want of a better word ‘crappy’ jobs, had just driven me to despair ...I didn’t feel like, after spending years at university, that I was doing what I should have been doing. I was using some of the skills, the mediation skills, the people skills, all that sort of thing, I was using all that, because it was sales. But I just didn’t feel, I don’t know … fulfilled.” Charles (45) Financial pressures can compel people who are mentally unwell to keep working. The necessity of having an income, and supporting a family, can drive people to keep working when they are mentally unwell. “I took a job on the railway, I worked for British Rail from the age of 19. I was getting married and I had a baby on the way at the time. … Desperate for work, so I took a job with British Rail even though I had some terrible problems with, I didn’t know it at the time, I was suffering with post-traumatic stress disorder from something that happened when I was 14. I took the job and I stayed there for five and a half years until eventually through ill health I had to leave, I left.” Ted (50-55) There is a clear tension between the need to leave work due to ill health and the negative effects of the loss of independent income that can have detrimental practical and emotional (loss of sense of worth and independence) impacts, which can damage mental wellbeing. “They made me redundant due to illness, and then found out that they weren’t going to cover me. The insurance wasn’t worth the paper it was written on. As you can imagine, that probably made me iller. Of course the house had to go on the market immediately. It basically just destroyed our lives.” Charles (45)
  71. 71. CASE STUDY SUSAN Susan is 60, married, with two adult children. She worked for over 20 years as a senior lecturer in Further Education, but took voluntary redundancy after a breakdown caused by stress at work. She felt that her concerns about her working conditions and various aspects of the job were not taken seriously. Susan had two months off sick, when her GP signed her off with sinusitis rather than stress. They did not discuss his signing her off with physical symptoms rather than mental ill-health, and she assumed this is because he felt that would be the best option for her. Upon her return, she stayed at work for another two years, during which time her health (both physical and mental) deteriorated significantly. She decided to leave and the opportunity presented itself when voluntary redundancies were offered. However, even if this hadn’t been the case she would have resigned anyway. She has had a variety of jobs since then, including running a guesthouse, and currently works full time for Mind. “At the end of 21 years I had a major meltdown - I couldn’t cope with it anymore, I just couldn’t handle it anymore… There were about three of us left and I’d been consistently physically ill which I now know was psychosomatic.”
  72. 72. MANAGING WORK / CASE STUDY USE OF DIGITAL Susan is digitally engaged. She uses a desktop at work and a laptop at home. She also has a smartphone which she mostly just uses for calling and texting. She uses her desktop at work to search for information about medication reviews for clients. She uses her desktop at work to search for information about medication reviews for clients, teaching materials, and sites/apps that might help clients, such as Blues Buster, Moodjuice and Time to Change. She uses twitter for work, mostly just to pass on information. She uses her laptop to access Facebook where she keeps in touch with family and a lot of friends who are scattered around Europe. She also uses pinterest a lot for crafts and creative ideas, and shops and banks on the internet. Usually she restricts herself to about an hour a day on the internet because it wears her out otherwise. She recognises that she uses facebook when she is feeling gregarious, and withdraws when she is ill. When she is struggling, she will text a close friend and they will arrange to call each other for a chat. Susan suggested that over-researching her symptoms or conditions on the internet would be, for her, “the sure route to suicide”. “I’d be absolutely obsessive if I did that. It would always be worst case scenario. It would be my road to ruination. I avoid it like the plague because I think a little information is a dangerous thing.”
  73. 73. SUSAN’S SUPPORT NETWORK This diagram illustrates who Susan goes to for support. His support network is mapped in terms of levels of trust and frequency of use.
  74. 74. Most used Least used Most trusted Least trusted Point of contact: Online Phone Face to Face Other Kind of support: Work related Mental health related Both Icon by Jens Tarning from the Noun Project Colleagues Friend Daughter Husband GP
  75. 75. High Low EMOTIONAL TIMELINE MENTAL HEALTH & WELLBEING EMPLOYMENT / EDUCATION Aged 18 - first job working with adults with special needs for 5 years. Aged 24 - youth and community work course - 2 years. Day care welfare office job - assistant directer - full times 2 1/2 years. Child minder training - had second child stopped child minding after that.second child. Was offered a job as child care lecturer - stayed for 21 years (did PGCE) leading to senior lecturer. Mental wellbeing improved with appointment as lecturer - loved the job. Left to have child, hepatitus concerns, post natal depression anxiety. Mental health wavered through birth of second child and job as child minder Got divorced from first husband. Needed financial recovery. SUSAN’S EMOTIONAL JOURNEY
  76. 76. Job pressures - changes in education lead to moral dilemma. Had break down, went to GP diagnosis of depression after a few physical problems - started anti depressants after drugs trial and seeing pschiatrist (6 sessions) then referred to group counselling. Met second husband. Post break down continued self monitering and anti depressants. Moved jobs and worked in car various jobs vaious roles for 12 years. Bought guest house ran it with husband. Did part time work on side. Working full time at Mind - great.
  77. 77. Katy is 24 years old and is now in full time employment in a social enterprise, she lives at home with her parents and boyfriend. Symptomatic from a young age, Katy has struggled with depression, anxiety and eating disorders for many years. Although she had a breakdown at university, Katy graduated and was excited about the prospect of work. She had already started volunteering with a youth mental health charity. However months of applying for work without any success, left her dispirited. “Then you leave university and you’re really optimistic but then reality kicks in and you think, ‘I’ve applied for 700 jobs and not heard a thing...’ The wait was a really low bit.” When Katy finally got an interview and offer for a job she wanted, she filled in a pre-employment health questionnaire being open about her mental health issues, unaware that she was not legally obliged to do so. As a result of her answers her potential employers then referred her to occupational health, and after a long wait decided that she was not fit to work with children and young people. This was a very traumatic moment for Katy. During this interim period she had been working in a bar to make ends meet. “It was a very fast paced bar and with my anxiety and other mental health problems it was a real struggle, especially as I’ve got quite a lot of visible self-harm scars. It was very difficult for me to come out, to be able to have sleeves rolled up at all. So I usually didn’t. I needed quite a lot of breaks because I was getting overwhelmed. So I ended up leaving that after about three months.” As described above, the bar work exacerbated her mental health issues as did her next job as a care worker for children with serious health problems which was stressful, isolating and often involved night shifts. This job took her to the point of breakdown. She put the word out via her contacts she knew from volunteering with youth mental health charities and got offered a job in the sector. She was then was headhunted for her current role in a social enterprise. She spoke of the relief she felt when she was finally able to work in a supporting and understanding environment where she could be open about her mental health issues: “It felt like freedom” CASE STUDY KATY
  78. 78. FULL TIME EMPLOYED / CASE STUDY Katy is very self-aware when it comes to her mental health issues. She has had a mixed experience of mental health services, both in terms of quality of provision and availability. Despite a history of eating disorders and severe depression, she had to wait 13 months for CBT. Katy has been using online mental health support since her teens. “I ended up setting up my first support group online when I was 13. Online support has been the one unbroken line that goes the whole way across. No matter where I lived geographically or what condition I was struggling with or what was going on online was the one thing that was continuity of care. 24/7 as well; it’s 365 days a year. So if I’m having a shit day on Christmas day, I have someone to talk to. I don’t have that with a mental health service necessarily. Especially, it helped me through the breaks between CAHMS and then seeing adult services, it helped me survive uni, it helped me when I was struggling with jobs.”
  79. 79. This diagram illustrates who Katy goes to for support. Her support network is mapped in terms of levels of trust and frequency of use. KATYS SUPPORT NETWORK USE OF DIGITAL Katy is a heavy user of digital. She has two phones (work and personal), two laptops (work and personal) and a tablet. She is online most of the time.To support her wellbeing, Katy uses Buddy App, in addition to a period tracker and a weight tracker. She is also part of many online mental health communities which give her valuable support.
  80. 80. Most used Least used Most trusted Least trusted Point of contact: Online Phone Face to Face Other Kind of support: Work related Mental health related Both Icon by Jens Tarning from the Noun Project Colleagues Friend Parents Nurse New GP Ex Colleagues Boyfriend CAMHS
  81. 81. High Low EMOTIONAL TIMELINE MENTAL HEALTH & WELLBEING EMPLOYMENT / EDUCATION Univeristy and volunteering with a youth mental health charity. Exams, University stress leads to breakdown. Treatement for breakdown, then support nurse and home treatment team. Diagnosed with depression from young age. Used online support communities for depression, eating disorders and anxiety. Saw GP while at University. On leaving University, Katy job hunts online. Struggles to find job after months of searching, feels very dispirited. Katy sees nutritionist. Is offered a job. Fills in pre-employment health questionnaire. While waiting works in fast paced bar. Left after 3 months. Working in bar exacerbated mental health problems. 13 month wait for CBT.
  82. 82. Ends up waiting a year, while new employers send her to occupational health based on the pre-employment questionnaire. Ends up being refused the job after they decide she is unfit to work with children. Hearing that she was deemed unfit to work with children was traumatic. Was head - hunted is now working at social enterprise. Full time job at mental health charity, that she got through her networks. Gets job as healthcare support worker. Isolated, stressful with long hours. Job is stressful, goes to see GP. KATY’S EMOTIONAL JOURNEY
  84. 84. This section examines the multiplicity of ways that interviewees support their psychological wellbeing, whether through self-management or accessing services. Interviewees described a variety of ways that they self-managed their psychological resilience such as exercise, spending time in nature, meditation, prayer, being part of a community and developing greater self awareness. When it came to mental health services, flexibility of treatment options was described as vital by interviewees as they felt they needed different treatments at different times. GPs were key service touchpoints, although there was a marked lack of consistency in the quality of they way they dealt with mental health issues. When talking about mental health services interviewees brought up wider, systemic issues such as long waiting lists and the fact that support is set up to deal with crisis rather than prevention. SUMMARY
  85. 85. MENTAL HEALTH SUPPORT / INSIGHTS ON EFFECTIVE SUPPORT INSIGHTS ON EFFECTIVE SUPPORT: SELF MANAGEMENT Here is a selection of some of the many different ways interviewees self-managed their mental wellbeing. Getting outside and active. “I do think that spending some time outside every day is a really good thing to do, which I mostly do. Like if it’s really wet or something I don’t always do that, but I think if you just go outside and either go for a run or walk, or go to the gym or something as a basic sort of routine ... that’s a good thing to do.” Alex (58) “Exercise. Exercise is good. That makes me very happy actually. I think if I didn’t have that I’d be quite frustrated and probably quite an angry person, I imagine. But yes that keeps me on a level playing field, so to speak.” William (30) “I was unemployed and a boyfriend had just broken up with me, I had had to move back home. I was like, “This is rubbish.” My brother and his girlfriend have horses, so I think I went around just to go and hang out. She was like, “You know, have a sit on a horse.” Then I was like, “This is brilliant.” So I started cycling up every day. I think just having the horses to look after, learning a new skill, and being out in the fresh air and doing exercise every day, I think that just helped. That was all it took, literally. It was like, “Oh, right. Amazing.” Susie (30) Developing meditation/prayer/gratitude practices. “I pray, I read daily. I speak to my friends in AA, in recovery every day. I write a gratitude list every day. I just try and think positively, just one day at a time. I try not to think about the future, tomorrow. Just today.” Caroline (42) “I also pray, it goes against the grain because I’ve always been quite anti-religious but through recovery, learnt to praise a higher power, that helps quite a lot. There was one [app] for writing a gratitude list. It’s like, “You haven’t been grateful for three days, come back”. I’m like, “Okay”. That was helpful. I don’t really go on it very much now. There were a couple of mindful things that I went on. I don’t go on them but I still get these little alerts through the day, like, “Take a pause”. So sometimes I do actually think, “Oh yes, what am I actually doing right now? how am I feeling?” Nita (22) “I stopped seeing the counsellor and realised that I was just going to have to deal with stuff on my own through whatever kinds of tactics – through my whole arsenal
  86. 86. of everything I’d learned from – I remember when I was seven, one of my aunties taught me how to make your body relaxed at night in bed. Make your body feel heavy and warm and relax it and all that sort of stuff. So just trying to draw on everything; meditation techniques and all that kind of stuff, try to do yoga in the morning, try to eat healthily and do exercise.” Wendy (35) Being part of a community. “I find that if you have a relapse or a breakdown there’s no point in staying among people who have the same problem. Well no, it’s not like there’s no point; it’s just that if you go back into the community as quickly as possible, you’ll be alright.” Gina (63) “As is finding other people, if you are working on your own, finding other people to share with or kind of provide mutual support is a really good thing to do.” Andy (58) “I’ve had a really good social network, albeit from the age of 12 to 21, that was basically one person but now I’ve got about six people who would be there in my hour of need. I know how to surround myself with people that I view as strong so I’ve got them to fall back on.” Josh (26) Developing self-awareness of mental health condition’s rhythms and triggers. “When I’ve worked I’ve given over 100%, which isn’t always helpful, you can get burnt out very quickly, which I’ve learned over the years, but it’s only just quite recently that I’ve understood that. So now, I put in what’s needed to a job, I don’t try and over exert myself and wear myself out.” Jen (55-60) “Just say to yourself, if I start going into a low, I mean my cycles tend to be probably about a week each. I will have a week down, a week up, and then be alright for a couple of weeks. But, when it is on the downs, you basically just say to yourself, “Well, give it another week and I will be fine.”” Charles (45) “I mean, to get around and everything I’ve got to wear these [headphones]. It’s music, it keeps me calm. When I’m walking down the road I put them in.” Derek (37) “I think I’ve got to a stage where I know my psychosomatic symptoms well enough to know that it’s not cancer or a brain tumour so I dismiss that out of hand. I know that this is stress related and I know why, I know that it will pass. I’ve carried this stuff around for years and you kind of get used to it really.” Susan (60)
  87. 87. MENTAL HEALTH SUPPORT / SERVICE TOUCHPOINTS SERVICE TOUCHPOINTS GPs are important touchpoints for many people and can provide a vital lifeline, however they can also be unhelpful and act as barriers to support. There is a lack of consistency when it comes to the ways GP engage with mental health issues. “The GP that I have now since I’ve been in London, she’s been amazing… She really sits down. She has been amazing. I can speak to her about work. The lady that I’m working for now, she’s hard work. My GP, she makes sure that I’m not overdoing it, so I don’t actually ever get to this stage again, because I’ve been with her now for seven years. Yes, so she’s seen a lot of up and down. She is really great, really good. Yes. It’s like talking to a friend. She really wants to help me.” Kellie (42) “My GP this time has been very good. Because she asked me to come in and see her first of all every two weeks, then every three weeks and now I can see her once per month. She wrote a referral and they had to see me within two weeks, I got all the tests done within two to three weeks. My GP was trying very hard to keep me out of hospital but I think I needed to go to hospital because I needed to get better properly.” Gina (63) “I’ve had difficult times with GPs. I was at a Medical Practice, which has 10 different doctors and I’d go to one for a little while and then they’d do something that I felt like they didn’t understand or they were having a go at me or whatever. So then I’d go to a different one… I saw a locum, saw her a couple of times and she was really good but then she left the surgery and she advised me to go to a different doctor, who wasn’t going to be going away from surgery and I went to see him and didn’t find him very good. So I went back last week and saw another new doctor, I think she’s probably a locum and yes, she’s been much better… It seems to be the people who are just coming out of their training seem to be more understanding of young people and mental health than the older doctors who… It feels like they have no idea what depression and anxiety is, and then on top of that, if they do understand it’s like they think young people can’t have it or it’s just a phase, you don’t know what you’re talking about. It’s a bit like, well, five years later it’s not really a phase anymore, is it? Yes, I’m a bit angry with doctors.” Nita (22) “Periodically I go back to my GP and he says, “How are you?” and I say, “Pretty much the same.” You don’t get an awful lot of mental health support through your GP really… I wouldn’t trust my GP as far as I could throw him, he couldn’t be less interested.” Susan (60) Community Practice Nurses can play an important, positive role for people with diagnosed mental health issues. Their informal visits to patients’ homes can provide relaxed, practical support and give them valuable insights into the service-user’s needs.
  88. 88. “… after my divorce I hit the lowest point ever and my doctor at the time, he got me a CPN, a community psychiatric nurse, who helped me. Again that was another good turning point in my life… it was helping me deal with my problems, the deep problems that I had and just helping me gain confidence and start feeling positive. I’ve never felt anything positive in my life and he made me feel positive, and look at the nice things in life rather than living in this dark world that I lived in. It was a massive turning point.” Ted (53) “My CPN suggested that I apply to be a volunteer for Mental Health Charity, which I really think was a stroke of genius because most people from the Community Mental Health Team are referred in to be supported by Mental Health Charity. I think he really judged that well. “This is somebody for whom it will be much more helpful to go in and volunteer because she is capable, she is intelligent. A good step back on the road to recovery.” Cara (31)
  89. 89. SYSTEMIC ISSUES The mental health system is set up to deal with crisis rather than prevention, This systemic focus on crisis can discourage people from seeking timely help, and thereby preventing mental health issues from escalating, as they feel like their condition isn’t serious enough to warrant support. “Even though I was feeling really, really horrible, I guess I was feeling that when people go and see therapists or psychiatrists, that is because they have real serious, deep issues. Even though that was really hard it was just one of those things that happens in life and you just have to work through those painful months and just continue.” Laura (29) “So I knew that the NHS was just not set up to handle how bad I felt about myself, until I got to the point where I was going to kill myself, and then all they were going to try to do is figure out how, within a certain window, not to get me to kill myself.” Wendy (35) Stella describes the attitude of her Community Health Team: “I suppose a bit like the attitudes now, “Well, yes you are obviously very depressed, but, you know, you cope and you manage your life, so we’re not really going to help.” (Laughter). Which, you know, is a bit like now, that, “You’re not a risk to yourself, particularly, you’re not a risk to anybody else, so get on with it and keep soldiering on.” So I did. Just kind of carried on.” Stella (36) The focus on crisis can also lead people to overplay their condition to get support: “That was a difficult period because, especially with eating disorders, there’s always a feeling that you have to stay sick because if you get to the assessment and you are over their weight threshold they won’t see you. I kind of felt like I had to stay ill because otherwise I wouldn’t be taken seriously and otherwise I wouldn’t actually get the help.” Katy (24) “Eventually I said, “No, look, I feel really suicidal, I need you to put me forward for therapy”. I didn’t feel suicidal.” Josh (26) A lack of focus on prevention, particularly with support around traumatic events like bereavement, divorce and illness, can lead to individuals developing serious mental health issues. We saw this with many interviewees. Roger (54) was as foreman in a factory, when he experienced the death of his twin brother and a divorce in 1996, he spiralled into drug and alcohol abuse and severe depression. He hasn’t been in paid employment since. MENTAL HEALTH SUPPORT / SYSTEMIC ISSUES
  90. 90. Gina (63) was a research scientist. When she moved to a new university for a post- doctoral position she experienced a lot of racism and had to move accommodation five times in a year. In her words, “I think that’s what brought on the breakdown. And you know that once you’ve had a breakdown it’s easy to relapse if you’re not careful”. Peter (51) was working in insurance when a difficult divorce pushed him into a downward spiral, “Well, my life went to pot then; I lost the job with the insurance company; drink driving and things. Well, I was off work for a while; I had, well, a breakdown, but I ended up doing even a short spell inside, for a few months.” He has not been in paid employment for 16 years.” Long waiting lists for mental health services means that many people do not receive the help they need. “The psychiatric nurses and the mental health social workers, they weren’t going to be able to provide me with what I needed. I wish they would. I’ve seen how hard it is to get to see a clinical psychologist. The waiting list for those things is 18 to 36 months. It depends on your area, and they just don’t refer a lot of people.” Wendy (35) “I went to see a doctor during this time, after I broke up with my boyfriend and had to keep living with him. I got put on a waiting list but the waiting list [to see a counsellor] was so long that it was never worth it.” Sonia (28) “So I never got any kind of counselling, which is what I think I would have benefitted from. I think there was just such a waiting list, I just got put on the list but never heard anything ever again.” Ceris (40)
  92. 92. When it comes to finding and staying in work, interviewees described the importance of skills identification, mentors, tailored support and reviews. People need these different elements of support across the employment journey. With regard to job seeking, the most common service touchpoints were the Jobcentre, recruitment agencies and job-hunting websites. The procedures, tools, and culture of Jobcentres were the key systemic challenges raised by interviewees. SUMMARY