5 Fairfax Mews, Off Fairfax Road
London N8 0NN
Tel: 0208 347 7225/6
Fax: 0208 881 2477
Advance Mental Health
09.30 Session 1
Introduction to course
09.45 Session 2
How to identify mental health problems and support
service users develop positive mental health
Including From Stress to Psychosis
Use of mental health legislation
11.00 Tea Break
11.15 Session 3
Person Centred Approach
Principles of Psychosocial intervention
Use of medication
2.00 Session 4
Case study – Depression
Practice skills – Motivation
Practice skills - Psychotherapy strategy
3.00 Tea Break
3.15 Practice skill – Working with difficult behaviour
4.10 Bringing it together
4.20 Course Evaluation
How to identify mental health problems and support the
service user develop positive mental health
What is good mental health?
Ladder of functioning
A good way to identify mental health problem is to look at our ladder of
N o lim it p e r s o n
G o o d fu n c tio n in g
le v e l
A n g ry
A n x io u s
M e n ta lly ill
Good level of functioning
No limit person
Wyne Dyer (1995) suggests that 5% of the population is in this category.
Functional areas affected by mental health problems
• Physical appearance, health and hygiene
• Biological functions: sleep, feeding, bowels, bladder
• Activity, energy, movements
• Verbal and non-verbal communications
• Mood and emotional reactions
• Perceptions of others, objects and environments
• Relationships and sexuality
• Self perception, insight and esteem
• Repertoire of adaptive and maladaptive behaviours
• Attention, thinking and learning
• Memory and attention
• Perceptions/attitudes to health and needs
How many people experience mental health problems?
On average 1 in 4 people will experience some kind of mental health problem in the course of
a year. However, of these, only a relatively small number will be diagnosed with a serious
and enduring mental health problem.
How many people experience mental health problems?
Mental health problems are found in people of all ages, regions, countries and societies.
• 1 in 4 British adults experience at least one diagnosable mental health
problem in any one year, and one in six experiences this at any given time.
• Although mental disorders are widespread, serious cases are concentrated among a
relatively small proportion of people who experience more than one mental health
problem (this is known as ‘co-morbidity’).
What are the main types of mental health problems?
• Mixed anxiety & depression is the most common mental disorder in Britain,
with almost 9 percent of people meeting criteria for diagnosis.
• Between 8-12% of the population experience depression in any year
• About half of people with common mental health problems are no longer affected
after 18 months, but poorer people, the long-term sick and unemployed people are
more likely to be still affected than the general population.
Who develops mental health problems?
• Women are more likely to have been treated for a mental health problem than
men (29% compared to 17%).This could be because, when asked, women are
more likely to report symptoms of common mental health problems.
• Depression is more common in women than men. 1 in 4 women will require
treatment for depression at some time, compared to 1 in 10 men. The reasons
for this are unclear, but are thought to be due to both social and biological
factors. It has also been suggested that depression in men may have been
under diagnosed because they present to their GP with different symptoms.
• Women are twice as likely to experience anxiety as men. Of people with
phobias or OCD, about 60% are female.
• Men are more likely than women to have an alcohol or drug problem. 67% of
British people who consume alcohol at ‘hazardous’ levels, and 80% of those
dependent on alcohol are male. Almost three quarters of people dependent on
cannabis and 69% of those dependent on other illegal drugs are male.
• In general, rates of mental health problems are thought to be higher in minority ethnic
groups than in the white population, but they are less likely to have their mental health
problems detected by a GP.
• One in four unemployed people has a common mental health problem
What about mental health problems among children and young people?
• One in ten children between the ages of one and 15 has a mental health disorder
• Estimates vary, but research suggests that 20% of children have a mental health
problem in any given year, and about 10% at any one time.
• Rates of mental health problems among children increase as they reach adolescence.
Disorders affect 10.4% of boys aged 5-10, rising to 12.8% of boys aged 11-15, and
5.9% of girls aged 5-10, rising to 9.65% of girls aged 11-15
What is the prevalence of mental health problems in older people?
o Depression affects 1 in 5 older people living in the community and 2 in 5 living in
• Dementia affects 5% of people over the age of 65 and 20% of those over 80.
About 700,000 people in the UK have dementia (1.2% of the population) at
any one time.
How common is suicide?
• In 2004, more than 5,500 people in the UK died by suicide
• British men are three times as likely as British women to die by suicide.
• Suicide remains the most common cause of death in men under the age of 35
• The suicide rate among people over 65 has fallen by 24% in recent years, but
is still high compared to the population overall
How common is self-harm?
• The UK has one of the highest rates of self harm in Europe, at 400 per
• People with current mental health problems are 20 times more likely than others to
report having harmed themselves in the past.
What is the relationship between mental health problems and offending?
• More than 70% of the prison population has two or more mental health
disorders. Male prisoners are 14 times more likely to have two or more
disorders than men in general, and female prisoners 35 times more likely than
women in general
• The suicide rate in prisons is almost 15 times higher than in the general population. In
2002 the rate was 143 per 100,0001 compared to 9 per 100,000 in the general
From Stress to Psychosis
Stress-Vulnerability Model of Psychosis
There are multiple causative factors in the development of psychosis but most research
suggests that the Stress-Vulnerability model of psychosis is the most dominant.
This model suggests that a vulnerability to psychosis is acquired through a genetic
predisposition or as a result of an environmental insult to the brain (e.g. head injury). This
vulnerability, however, is not considered to be sufficient to manifest the disorder and must be
'triggered' by environmental processes. The environmental component can be biological (i.e.
an infection, or even drugs and alcohol) or psychological (stressful living situation, school
exams, travel etc.).
• vulnerability to psychosis is acquired through a genetic predisposition, or as a
result of an environmental insult to the brain.
• to manifest, the disorder must be 'triggered' by environmental processes
• the amount of environmental stress needed to 'trigger' psychosis likely differs
from person to person, as does the amount of vulnerability that at risk people
have for psychosis.
The 'stress' component of the model may take many forms, including:
• Traumatic life events.
• Use of drugs and alcohol.
• Stressful living conditions (e.g., low socioeconomic status; high levels of family
DECREASED STRESS TOLERANCE
There is also some agreement that people with psychosis handle stress poorly. It seems that
they have a low tolerance for stress - things that would have not been stressful for someone
who does not have psychosis can prove too much for those who do have it. There is also a
lower tolerance of intense emotions from others, e.g. anger, criticism, conflict or extremes in
positive concern or over involvement. Clearly this makes knowing how far to push or
encourage someone to do something a difficult decision. On the one hand too much pushing
may lead to problems and even relapse, whereas no encouragement to do things may see
someone sink into apathy and withdrawal.
Certain factors can also reduce the risk that an at-risk person will develop psychosis:
• Use of appropriate prescription medication.
• Use of stress management techniques.
• Reliable support systems (e.g., family, a hospital day program).
Use of Mental Health Legislation
Mental Health Act 1983 and Mental Health Act 2007 is primarily Civil Rights
Legislation used to manage people with Mental Illness in 3 settings, namely,
1. In the Community
2. In Hospital
3. In Criminal Justice System
In a nutshell MHA 1983 and 2007 enable people with mental illness to get
treatment when they need it with minimal infringement of their civil
• It outlines when a person can be detained.
• How the person should be treated by Hospitals.
• What support mechanisms should be in place for after care of the
service used on discharge from hospital
The MHA also establishes how people who commit offences when mentally
ill should be treated and supported via the health system working along
side the Criminal Justice System
In the Community
• Voluntary admission
• Compulsory admission
• After Care Support
Discharge into community
• Sec 117 discharge
• Supporting People
• output linked
• Relapse prevention
In the Hospital
• Category 1 - Medication
• Category 2 – ECT and Hormonal
• Category 3 – More invasive treatment
• Talking therapy
Rights in hospital
• To MHRT
In Criminal Justice System
Similar to the Civil System with more controls and mandatory orders
Mental Capacity Act 2005
European Human Rights Act 1998
NHS and Community Care Act 1991
The Human Rights Act 1998 furthers the Civil Rights of people with
mental illness by further defining additional rights that people with mental
illness have such as rights to establish a family, right to choose e.g.
The Mental Capacity Act establishes the principle that everyone has
mental capacity. It outlines processes by which it can be confirmed that
the person’s capacity is diminished due to mental illness, how he/she can
be supported to make decisions that enhance their own best interest.
The funding for mental health services comes from a number of sources
such as the NHS and Community Care Act 1991, the National Service
Framework of Mental health, National Service Framework for Elders,
Supporting People Funding, Housing related funding.
This funding working alongside the legislation creates a climate for safe
service provision which is further boosted by Care Standards Act 2000 and
CSCI inspectorate which inspects and reinforces service standards.
The rights of Minority Ethnic community is also protected by the Race
Relations Act 1976 and its Amendments in year 2000.
Person Centred Approach
This approach puts the person at the centre and enable/supports the person to
develop a picture of quality of life the person wants to lead by exploring the following
areas with the person and then supporting the person achieve their aspirations in
Key area Objectives
• Physical Health
• Mental Health
5. Personal Development
9. Emotional Regulation
10. Drugs use
11. Alcohol use
12. Support Network
15. Day Care
Principles of psychosocial intervention
The term psychosocial intervention has come to refer to any programme
that aims to improve the psychosocial well-being of the service user
Psychosocial interventions support the service user to cope with their
mental health condition, and help the quality of life. (Slade and Haddock
1996) These interventions are also beneficial to relatives, and are
effective in improving the quality of family environment (Penn and Mueser
Key working is generally a key component of delivering psychosocial
intervention in mental health care.
Research suggests that establishing a therapeutic alliance is essential to
the success of psychosocial interventions.
The interventions are made up of:
• Information and advise giving
• Harm reduction interventions e.g. support the person get
appropriate medication, supporting the person get housing, help
person reduce chaos in their life created by mental health difficulties
• Service user education to take reduce chaos in their life, manage
their mental health symptoms and relapse prevention.
• Cognitive-behaviour interventions to manage mental health
• Social skills development/support/training
• Family intervention
A typical protocol for using psychosocial intervention is:
• Take referral
• Carry out risk assessment
• Develop a collaborative working relationship with service user
• Enable harm reduction
• Support the person through recovery
• Empower the person to take control over their life
• Provide support to remain independent in the community
• Help the person to participate in contributing to community life
• Support the person establish their relapse signature and empower
them to use the care system effectively to remain well in the
Commonly Prescribed Mental health medications:
Mental health medications are used to provide relief from mental health
Listed below are two tables of commonly prescribed psychotropic mediations. The
first table is a listing of medications based on their psychiatric use. This table
includes brand names and their generic form in parentheses. The second table
provides a cross-reference by generic name.
As with all questions about medication, be sure to consult with your prescribing
physician or pharmacist for any specific questions you may have about dosage, drug
interactions, or side effects.
Haldol (haloperidol), Haldol Decanoate
Moditen (fluphenazine), Prolixin Decanoate
Epilim (valproic acid)
Lithonate (lithium carbonate)
(oxazepam) (Generic only)
*Antidepressants, especially SSRIs, are also used in the treatment of anxiety.
*Antidepressants are also used in the treatment of panic disorder.
Stimulants (used in the treatment of ADD/ADHD)(Attention Deficit Hyperactive Disorder)
*Antidepressants with stimulant properties, such as Norpramin and Wellbutrin,
are also used in the treatment of ADHD.
Generic Name Brand Name Current Uses
alprazolam Xanax anxiety, panic
amitriptyline Triptazol, Lentizon depression
amoxapine Asendin depression
atenolol Tenormin anxiety
buspirone BuSpar anxiety
carbamazepine Tegretol bipolar disorder
chlordiazepoxide Librium anxiety
chlorpromazine Thorazine schizophrenia
citalopram Cipramil depression, panic, anxiety
clomipramine Anafranil OCD, depression
clonazepam Rivotril panic, anxiety
clorazepate Tranxene anxiety
clozapine Clozaril schizophrenia
dextroamphetamine Dexedrine ADHD
diazepam Valium anxiety
doxepin Sinequan depression
fluoxetine Prozac depression, OCD, panic, anxiety
fluphenazine Moditen schizophrenia
fluvoxamine Favrin OCD, depression, panic, anxiety
gabapentin Neurontin bipolar disorder
haloperidol Haldol schizophrenia
imipramine Tofranil depression, panic
1. ANTIPSYCHOTIC MEDICATIONS
Sedation, dry mouth, muscle stiffness, muscle cramping, tremors, EPS or
Extrapyramidal symptoms (akinesia - inability to initiate movement and akathisia -
inability to remain motionless)and weight-gain.
Weight gain and diabetes
2. ANTIMANIC MEDICATIONS
Used for Bipolar.
Side effects of lithium.
Initially, the person may have slight nausea, stomach cramps, diarrhea, thirstiness, muscle
weakness, and feelings of being somewhat tired, dazed, or sleepy. A mild hand tremor may
emerge as the dose is increased. These effects are normally minimal and usually subside after
several days of treatment. But some of the initial side effects may carry over into long-term
therapy and others may emerge. Some patients continue to have a slight hand tremor. Many
drink more fluids than usual-without always being aware of it--and urinate more frequently,
while still others may gain weight. Weight gain often can be controlled with proper diet.
Anticonvulsants used for bipolar disorder include carbamazepine (Tegretol), lamotrigine
(Lamictal), gabapentin (Neurontin), and topiramate (Topamax).
The other anticonvulsant valproic acid (Depakote, divalproex sodium) is the main alternative
therapy for bipolar disorder.
Dizziness, drowsiness, unsteadiness, nausea, and vomiting. Skin rashes may occur.ide effects
3. ANTIDEPRESSANT MEDICATIONS
Side effects of antidepressant medications. Antidepressants may cause mild, and often
temporary, side effects (sometimes referred to as adverse effects) in some people. Typically,
these are not serious. However, any reactions or side effects that are unusual, annoying, or
that interfere with functioning should be reported to the doctor immediately. The most
common side effects of tricyclic antidepressants, and ways to deal with them, are as follows:
• Dry mouth—it is helpful to drink sips of water; chew sugarless gum; brush
• Constipation—bran cereals, prunes, fruit, and vegetables should be in the
• Bladder problems—emptying the bladder completely may be difficult, and the
urine stream may not be as strong as usual. Older men with enlarged prostate
conditions may be at particular risk for this problem. The doctor should be
notified if there is any pain.
• Sexual problems—sexual functioning may be impaired; if this is worrisome, it
should be discussed with the doctor.
• Blurred vision—this is usually temporary and will not necessitate new glasses.
Glaucoma patients should report any change in vision to the doctor.
• Dizziness—rising from the bed or chair slowly is helpful.
• Drowsiness as a daytime problem—this usually passes soon. A person who
feels drowsy or sedated should not drive or operate heavy equipment. The
more sedating antidepressants are generally taken at bedtime to help sleep
and to minimize daytime drowsiness.
• Increased heart rate—pulse rate is often elevated. Older patients should have
an electrocardiogram (EKG) before beginning tricyclic treatment.
The newer antidepressants, including SSRIs, have different types of side effects, as follows:
• Sexual problems—fairly common, but reversible, in both men and women.
The doctor should be consulted if the problem is persistent or worrisome.
• Headache—this will usually go away after a short time.
• Nausea—may occur after a dose, but it will disappear quickly.
• Nervousness and insomnia (trouble falling asleep or waking often during the
night)—these may occur during the first few weeks; dosage reductions or time
will usually resolve them.
• Agitation (feeling jittery)—if this happens for the first time after the drug is
taken and is more than temporary, the doctor should be notified.
• Any of these side effects may be amplified when an SSRI is combined with
other medications that affect serotonin. In the most extreme cases, such a
combination of medications (e.g., an SSRI and an MAOI) may result in a
potentially serious or even fatal "serotonin syndrome," characterized by fever,
confusion, muscle rigidity, and cardiac, liver, or kidney problems.
The small number of people for whom MAOIs are the best treatment need to avoid taking
decongestants and consuming certain foods that contain high levels of tyramine, such as many
cheeses, wines, and pickles. The interaction of tyramine with MAOIs can bring on a sharp
increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list
of prohibited foods that the individual should carry at all times. Other forms of
antidepressants require no food restrictions. MAOIs also should not be combined with other
antidepressants, especially SSRIs, due to the risk of serotonin syndrome.
4. ANTIANXIETY MEDICATIONS
Both antidepressants and antianxiety medications are used to treat anxiety disorders.
Antianxiety medications include the benzodiazepines, which can relieve symptoms within a
short time. They have relatively few side effects: drowsiness and loss of coordination are
most common; fatigue and mental slowing or confusion can also occur. These effects make it
dangerous for people taking benzodiazepines to drive or operate some machinery. Other side
effects are rare.
The only medication specifically for anxiety disorders other than the benzodiazepines is
buspirone (BuSpar). Unlike the benzodiazepines, buspirone must be taken consistently for at
least 2 weeks to achieve an antianxiety effect and therefore cannot be used on an "as-needed"
Beta blockers, medications often used to treat heart conditions and high blood pressure, are
sometimes used to control "performance anxiety" when the individual must face a specific
stressful situation—a speech, a presentation in class, or an important meeting. Propranolol
(Inderal, Inderide) is a commonly used beta blocker.
5. Medications to manage side effects
Procyclidine hydrochloride is used in patients with schizophrenia to reduce the side effects of
antipsychotic treatment, such as parkinsonism and akathisia
MEDICATIONS FOR SPECIAL GROUPS
Children, the elderly, and pregnant and nursing women have special concerns and needs when
taking psychotherapeutic medications. Some effects of medications on the growing body, the
aging body, and the childbearing body are known, but much remains to be learned. Research
in these areas is ongoing.
Working with challenging behaviour
Mental illness in a person can lead to behaviour in a service user which
from time to time is difficult to deal with by service providers e.g. Non
engagement with service providers, over use of alcohol and illicit
substances, demotivation, sleep disturbance, eating patterns and so on.
This means that organisations that provide services to people with mental
illness have to provide guidelines on how to work safely and effectively
with service users.
Any guideline in working with people with mental illness needs to be
underpinned by duty of care which is made up of:
Welfare – whatever the staff do has to promote the long term welfare of
the service user
Support – staff need to provide support now that enables to person to
cope with their situation and address disadvantages brought on by mental
Protection – ensure that the person with mental illness is supported to
protect themselves from abuse
In providing services to a person with mental illness who may have
complex needs and present challenging behaviour, evidence based
practice suggests that staff should use good practice protocols.
These protocols need to address individual’s service uses unique needs
A typical protocol would be made up of:
• Comprehensive assessment
• Risk assessment
• Care management arrangement
• With key working practice
• Appropriate medication
• Harm reduction practice
• Recovery from mental illness
• Re-engagement of the community
• Relapse prevention
The practice in all these areas would be guided by organisations policy
and practice as well as knowledge base developed by practitioners and
How to do effective counselling?
• Supporting the person take responsibility
• Enabling the person to solve their own problems
• Empowering the person to take control of their own life
Protocol for supporting recovery
1. Identify issues
2. Risk assessment
2.1 Motivation comes from pain or pleasure
3. Reducing chaos and enabling recovery
3.1.Increase energy to change - Sleep
3.2 Addressing the internal demotivator - Increasing enjoyment
4.1 Activating the Person
4.1 Addressing persons moods using thought patterns
4.2 Enaging person’s schemas – Downward arrow technique
5.1 Engaging person in daily life
• Mental health
• Emotional regulation
• Day activity
• Personal development
Next 6 months
• Issues from past
• Issues in present
• Issues from future
7. Working with difficult behaviour
• Success formula
• Role modelling
• New Associations
• New habits
Key Issues Risk (High, Medium, Low)
COGNITIVE THERAPY BOOK LIST
COGNITIVE THERAPY OF SUBSTANCE ABUSE by Aaron T. Beck, Fred D. Wright,
Cory F. Newman, and Bruce S. Liese (Paperback - 30 April 2001)
COGNITIVE THERAPY - BASICS AND BEYOND by Judith S. Beck. (1995) Library
COGNITIVE BEHAVIOURAL THERAPY: RESEARCH, PRACTICE AND
PHILOSOPHY. by Brian Sheldon (Routledge, 1995) £12.95
COGNITIVE BEHAVIOUR THERAPY IN ACTION by P. Trower, A. Casey, W.
Dryden (Sage, 1986) £10.99
COPING WITH DEPRESSION by Dr Ivy-Marie Blackburn
MIND OVER MOOD (Patients' and Therapists' Manuals) by Dr D. Greenburgh and
Dr Christine Padesky
COGNITIVE THERAPY AND THE EMOTIONAL DISORDERS by Aaron T. Beck,
M.D. (Meridian, USA. 1976 )
COGNITIVE THERAPY OF PERSONALITY DISORDERS by Aaron T. Beck, Arthur
Freeman and Associates (The Guilford Press, USA. 1990)