Socially inclusive practice - British Psychological Society [PDF]

Professional Practice Board Social Inclusion Group

Discussion paper Socially inclusive practice

Commissioned through the Standing Committee for Psychologists in Health and Social Care

Contents Page 1

Foreword

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Social Inclusion Working Group details

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Context and scope

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Section 1: Definitions and history

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Policy drivers

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BPS activity and Society position

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Section 2: Examples of inclusive practice

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Section 3 Assessing the inclusiveness of services and practice

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Looking ahead

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References

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Foreword From the perspective of an Applied Psychologist This, the Society’s first paper of many to come on social inclusion, attempts to illuminate some increasingly familiar and hopefully widespread aspects of the considerable breadth and depth of activity that is required to create an inclusive societal process that supports the integration of people with mental health problems as full contributing and valued citizens. Here are the beginnings of an approach that is prepared to move beyond the boundaries of the traditional care system and work with communities to remove barriers to participation and involvement. Every aspect of this work has its place in a socially inclusive society and anecdotally at least it is the synergy between all the parts that practitioners will tell you leads to real change. Putting all the seemingly disparate aspects of social inclusion together and taking into account their different areas of focus, levels of intervention and cross-disciplinary and cross-institutional activities using a whole systems approach is almost unheard of in the UK. However, there are one or two exceptions, for example Bromley (see www.developbromley.com) where the support of an applied psychologist in a lead developmental role has been influential in developing an approach to partnership working that is comprehensively including at many levels. It will be interesting to note the future development of increasingly more concerted systemic approaches such as these as the whole systems approach reaches the level of commissioning for socially including mental health services. This paper utilises a useful framework (the Capabilities for Inclusive Practice, CSIP, 2007) to showcase current practice examples of socially inclusive or socially including psychological work. Also acknowledged is the importance of the ‘softer’ roles of psychological activity in the everyday life of service development. Using such approaches, applied psychology broadens out from often individual or group focussed interventions to develop understandings of human behaviour that can energise communities’ available social capital and ‘oil the wheels’ of organisational and social change, facilitating services and communities to jointly take on the challenge of making themselves not only including but capably inclusive. This also alludes to a training and consultancy role that should emerge in due course. Future papers from across the Divisions within the Society will begin to address these developmental practices from a range of perspectives applied to a range of settings. Dr Fabian Davis, on behalf of the BPS Social Inclusion Working Group

From the perspective of a service user For people with mental health problems, particularly those of us with complex and ongoing needs, living a life that is largely outside mainstream society has been, and indeed often still is, the norm. Acknowledgement of this unacceptable situation is the first step to tackling it – someone has at last noticed. Clearly there will not be a quick win as the negative attitudes that we face are ingrained in all layers of communities. It will take a concerted effort over a sustained period to ensure people with serious mental health

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problems are fully engaged and valued in society. It is heartening to hear of the development and implementation of a whole raft of approaches aimed at the wider society as well as equipping service users to not only counter exclusion in its many guises but also to flourish. Alongside this positive action, serious consideration should be given to an approach which ensures individuals are not disempowered in the first place or, in other words, ‘prevention is better than cure’. Mental health services have long been part of the problem with a strong focus on illness and the medical model coupled with misplaced paternalism and low expectations. Whilst some disempowerment appears unavoidable, such as when people are detained under mental health legislation, mental health and other related services are well placed to lead on an approach which focuses on us as individuals with strengths, opinions and aspirations as well as experiencing problems and needs. Kay Sheldon, on behalf of the DCP Service User & Carer Liaison Committee

Group details The social inclusion group is a working group of the Professional Practice Board. Members of the group who contributed to the development of this paper were: Dr Mark Hayward

Chartered Clinical Psychologist, University of Surrey & Sussex Partnership NHS Foundation Trust

Dr Ché Rosebert

Consultant Clinical Psychologist, East London NHS Foundation Trust

Dr Fabian Davis

Consultant Clinical Psychologist (Community & Social Inclusion), Oxleas NHS Foundation Trust

Kay Sheldon

Service User representative, DCP Service User & Carer Liaison Committee

Nigel Atter

Policy Advisor (Professional Practice), The British Psychological Society

Peter Kinderman

Professor of Clinical Psychology, University of Liverpool

The group would also like to acknowledge the significant contributions of: Mike Wang

Professor of Clinical Psychology, University of Leicester

Emily Brown

Deputy Director, Service User Involvement Directorate, Together

Naomi Hankinson

Assistant Director for Innovation & Development, National Social Inclusion Programme

Janet Bostock

Clinical Psychologist, Northumberland Tyne & Wear NHS Trust

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Context and scope The social inclusion agenda is broad, in terms of the people whose needs are considered and their location and demographics. Initially focused upon the exclusion of adults with mental health problems (Office of the Deputy Prime Minister, 2004), the needs of children, young people and families have recently been prioritised by the Government in the UK (Social Exclusion Task Force, 2006, 2008). Geographically, consideration has been given to the needs of people excluded (or vulnerable to exclusion) from their communities across Europe. Within the European Union key messages have emerged from member states in relation to a range of issues including the reduction of child poverty, balancing access to welfare benefits and making work pay, and the needs of ageing populations (Mental Health Europe, 2008). The British Psychological Society (BPS) is seeking to become more involved in activities related to these policy drivers. To date, specific activity has involved the Society contributing through the Care Services Improvement Partnership’s National Social Inclusion Programme (NSIP) to the development of socially inclusive capabilities for the workforce who provide mental health services to working age adults in England (CSIP, 2007). The authors’ aspiration is to see psychological work more broadly applied across the lifespan and to influence policy through greater involvement in implementing the inclusion strategies of the UK Government and the EU. This paper will primarily serve as a first step – a way of raising awareness about issues of inclusion and exclusion and encouraging reflection upon ways that applied psychologists might facilitate change. The primary focus is on the work of clinical psychologists in relation to the mental health of working age adults as this reflects recent activity in the Society, but in no way negates the need to work across the lifespan and engage the specific expertise of other psychologists within the applied psychology workforce. This will involve extensive engagement across the Divisions within the Society. The discussion paper is divided into three sections: ■

Section 1 will seek to define social inclusion and explore further the policy context around the social inclusion agenda;

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Section 2 will use the Capabilities framework (CSIP, 2007) to offer examples of inclusive practice, and reflections on those examples from someone who use mental health services; and

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Section 3 will ask the reader to reflect upon the extent to which the current practices of their service are inclusive.

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Section 1 Definitions and history A consideration of the context to people’s lives and problems is not new to the profession of Clinical Psychology. The Division’s Professional Practice Guidelines (DCP, 1995) state that: Psychological health is strongly influenced by context. It is essential that Clinical Psychologists pay attention to the influence of race, gender and culture in the expression of psychological difficulties and the professional response, and the relationship of these variables to the accessibility and acceptability of services. An understanding of context within a therapeutic framework may be informed by Narrative approaches (e.g. Vassallo, 1998) that concentrate on the self-image and the service user’s story of how they came to be who they are. Because of the discrimination attached to mental health problems in our society and the tendency to self-stigmatise, an individual’s story may need to be ‘retold’ to emphasise positive aspects of self and experience as opposed to the more often told story of self blame, guilt and shame (Davis & Turpin, 2004). Yet, practicing in a socially inclusive manner asks applied psychologists to go beyond merely paying attention to context: Socially inclusive practice seeks to make explicit links between the needs, identity, aspirations and behaviour of individuals in distress (or who experience disability), and the needs, identity, aspirations, and behaviour of their local communities or communities of interest. The process of creating a safe space for personal exploration (the recovery approach), the gathering of information (person-centred work), enhancing awareness, negotiating opportunities and appropriate interdependence (bridge building) and supporting autonomy (self-directed support) may involve the practitioner working with individuals in distress, their family and friends and pivotal members of local communities. Change will culminate in an individual who experiences a personally meaningful life and is able to make choices and contribute to their community in ways that are valued. A useful framework in this respect may be drawn from Community Psychology (e.g. Orford, 2008), where links between mental health, physical health and social capital (the energy available in a community over and above that required for survival that binds people together for mutual benefit) are well documented. Community psychology works with groups and communities to enable the growth of capacity within the community to deal with peoples’ adverse circumstances, helping to bring to the fore previously hidden resources of self-efficacy and personal development. When fostered, these resources can lead to increases in social capital and the capacity of communities to be self directed and supportive to their membership rather than excluding and oppressive (Community Psychology in the UK, see www.compsy.org.uk).

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Policy drivers In 2004, in part as a result of lobbying from a number of psychologists, the Social Exclusion Unit (SEU) agreed to consider what more could be done to reduce the social exclusion of working age adults with mental health problems. The report focussed on employment and equitable social participation (ODPM, 2004) and a number of key issues were highlighted: ■

the impact of stigma and discrimination against people with mental health problems – national action was required to promote behavioural change, but had so far been poorly funded and co-ordinated;

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the need for support to gain employment – perceived as a low priority for health and social care services, despite evidence linking return to employment with improved mental health;

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the perceived threats of leaving the benefit system – mechanisms to support the transition to work are too complex and easily misunderstood;

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lack of social networks and access to social activities leads to pervasive feelings of isolation and a reduced likelihood of recovery; and.

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professionals across sectors too often have low expectations of what people with mental health problems can achieve.

A 27-point action plan was proposed. Launching the SEU’s report in June 2004, Rosie Winterton, Minister for Health, said: ‘Social inclusion for people with mental health problems is a moral imperative.’ Responsibility for implementing the action plan fell to the National Social Inclusion Programme (NSIP), a cross-departmental government initiative hosted within the National Institute for Mental Health in England (NIMHE) which will run until 2009 – see www.socialinclusion.org.uk. Amongst the significant achievements of NSIP (2007) to date have been: ■

Publication of Vocational Services for People with Mental Health Problems: Commissioning Guidance, which provides a framework to commission evidence-based vocational services.

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Publication, dissemination and ongoing implementation of Direct Payments for People with Mental Health Problems: A Guide to Action.

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Abolition of the hospital down rating from April 2006, resulting in people within inpatient settings maintaining benefits and consequently the financial means to pursue and maintain the community activities/and relationships that can promote inclusion.

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Support for the establishment of Shift, a communications driven programme to reduce stigmatising, discriminatory coverage of mental health problems within the media.

In 2006 the government transferred responsibility for its social inclusion agenda to the Social Exclusion Task Force (SETF) located within the Cabinet Office. Committed to working with stakeholders and giving a voice to disadvantaged groups within government, the SETF’s action plan (Reaching Out: An Action Plan for Social Exclusion, 2006) drew attention to the needs of deprived and excluded children, young people and adults living

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‘chaotic lives’ (multiple needs and in contact with multiple agencies). Action will include the development of strategy, policy and pilot interventions to enhance the support and inclusion of children in care, pregnant teenagers and their families. Actions for adults leading chaotic lives will focus upon employment opportunities. Most recently, a further report has focused upon the circumstances and needs of the most excluded families in Britain, placing a particular emphasis on the intergenerational transmission of exclusion, and strategies to face the challenge of engaging such families in ‘whole family approaches’ (SETF, 2008).

BPS activity and the Society position The Society has worked with NSIP over the past two years to assess and develop the socially inclusive practices of the mental health workforce in the UK. A collaboration with the other four major professions within mental health (nursing, social work, psychiatry and occupational therapy) has created a framework for the assessment and development of Capabilities for Inclusive Practice (CSIP, 2007). Based upon the Ten Essential Shared Capabilities (Hope, 2004) to which the Society had also previously contributed, the framework prompts reflection upon inclusive practices at the level of the individual practitioner, mental health teams and organisations. Within the Society the framework is being used to exert an influence upon postgraduate and undergraduate curricula. Operationally the framework will be used as an audit tool by workforce planners within the NHS to assess the practices of the mental health workforce. Wider social inclusion issues have also been addressed recently in the Society publication: New Ways of Working in Teams (Onyett, 2007). The general issue of social exclusion is also being taken up by the Professional Practice Board in a number of work-streams to connect with the priorities of the SETF, for example, children and families, offenders in prison and return to employment. Psychologists from across the Divisions are actively involved in taking this work forwards on behalf of all applied psychologists.

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Section 2 The aim of socially inclusive practice is to (directly or indirectly) facilitate social inclusion through access to a range of resources, for example, social networks, social support, good neighbourliness, secure housing, financial security, education and learning, a respected social position, and good employment opportunities and conditions. Inclusive practice can also move from individually focused practice to mental health promotion and prevention of mental distress within communities – engaging with sections of or whole communities. It requires being open to communication with people and services outside of mental health. Practicing inclusively is about identifying needs and ways in which these can be met both inside and outside of mental health services. It is about awareness raising, facilitating links and supporting relationships between individuals, families, communities, services and organisations.

Examples of inclusive practice In this section examples of socially inclusive practice led by clinical psychologists and their colleagues will be given. The examples are followed by reflections from a member of the DCP Service User and Carer Liaison Committee. Whilst the examples given illustrate the work of individual psychologists it is important to remember that they work as part of teams and have support from and work with colleagues, managers and organisations that enable them to do this work. CSIP (2007) recommend that individual practitioners: 1.

ensure socially inclusive interventions are built into personal and team objectives;

2.

highlight good and emerging practice both within and beyond the team, service and organisation;

3.

challenge practice that is not inclusive; and

4.

contribute to developing a shared vision of local community, through engaging with important individuals and organisations.

The examples given below are not intended to be prescriptive, but illustrate where clinical and community psychologists can and have used their skills to promote socially inclusive practice. The practice examples illustrate one or two aspects of each capability. Please refer to the CSIP (2007) guidance for a full account of each Capability.

Essential shared capability 1: Working in partnership ‘Work actively to build, maintain and sustain partnerships with other community agencies so as to foster understanding, access resources and create a wide spectrum of opportunities for people with mental health problems. This work is recognised and valued by the mental health organisation’ Working with employers & employment agencies Promoting social inclusion is the current priority for Northumberland’s Mental Health Partnership Board. An action plan to reduce social exclusion includes enabling access to employment, community participation and activities, direct payments and housing. Jan Bostock, Clinical and Community Psychologist, has

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collaborated in a number of social inclusion projects that aim to reduce social inequalities and promote mental health for whole communities. These include: ■

Working with service users and other agencies to raise awareness of the impact of financial exclusion, and to promote the well-being of people on low incomes. This includes briefing local policy makers, as well as minimising breaks in benefits by improving information to mental health service users and staff. The group have developed a user-friendly guide to benefits and debt management for in-patients. They have also raised awareness of permitted/voluntary work and benefit linking rules through the welfare rights service’s newsletter (Benefits Matters).

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Facilitating a group of service users and providers who are working with local employers and businesses to raise awareness of mental health issues, how to prevent these, how to support people at work, and how to facilitate the gaining and retaining of employment for people with mental health problems if they so wish. The group is working on the development of courses and a Mental Health Promotion Charter for employers.

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Developed a resource for new managers about the causes of distress, and how to identify and prevent difficulties. The Well-being Resource Book for New Managers outlines the key influences on mental health and gives practical guidance about preventing stress at work as well as managing situations when people are struggling with their mental health. This resource has been well received by local staff and employers, trade union representatives and managers.

For more information please contact Ms Jan Bostock, Adult Mental Health Clinical Psychology Lead & Community Psychology Lead; e-mail [email protected]

Reflections from a service user perspective Long term unemployment is a major issue for people who use mental health services. The resulting poverty means we are simply not able to do many of the things that most people take for granted – going out socially, buying new clothes or furniture, going on holiday, having decent housing, running a car, even starting a family. Whilst you can survive on a low income, there is little else you can afford to do. As well as the financial disadvantages, lack of employment or meaningful activity makes it much more difficult to respect yourself and feel that you are a full and valued member of the community: what do you say when someone asks ‘What do you do?’ Encouraging service users into employment is not new, but what is new is the recognition of the barriers that we face in achieving this, both in the external environment in the form of ignorance, prejudice and discrimination, and also within ourselves such as lack of confidence, motivation and hope. Looking at and addressing wider issues is most welcome. A multi-pronged approach which supports service users to prepare for, obtain and keep employment as well as educating and working with employers would seem a robust and encouraging way forward.

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Essential shared capability 2: Respecting diversity ‘Have a strong social awareness of the diversity of the customs and practices and values in different social communities and across rural and urban environments.’ Engaging the public I have helped establish a series of public meetings that meet monthly in two local areas to discuss social, spiritual and personal approaches to mental health (called Evolving Minds meetings). The diverse understandings that develop from these forums creatively inform my work with individuals and colleagues. Our organising of public debates and dialogues about mental health systems and problems has lead to the staging of several national political demonstrations that have highlighted and challenged the use of coercion in psychiatric treatment. These public initiatives are designed to challenge dominant prejudicial narratives perpetuated in the media of people with mental health problems being highly dangerous and not having a valid voice or perspective. We hope these activities will dilute the pervasive processes that limit the roles and opportunities available to people within their communities. Rufus May – taken from Hayward et al., 2007 (p.28) For more information please contact Dr Rufus May, Clinical Psychologist; e-mail [email protected]

Reflections from a service user perspective For most people, social inclusion is about being accepted and respected within the communities that we live. Many of us with mental health difficulties do not feel integrated within society, overwhelmed by feelings of being different and not understood. I have often felt on the outside, that I didn’t really “belong”. Communities seem such an obvious place to start when challenging prejudice and erroneous beliefs. I feel it is vital that mental health service users take the initiative to create an independent service user/survivor movement that complements or even challenges mainstream approaches to social inclusion. Working in partnership is a useful and valid approach but, by its very nature, will inevitably be influenced by the agenda of others. However, having “unshackled” service user/survivor perspectives, although sometimes the more challenging and difficult route, is vital to ensure progressive ideas and attitudes. Working within communities creates the opportunity to learn about and understand ourselves and each other. We can learn to accept and value differences. If “mainstream” society, including and in particular mental health services and professionals, can see the value and legitimacy of this, then we really will have moved on.

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Essential shared capability 3: Practicing ethically ‘Recognise the rights and aspirations of service users and their families, acknowledging power differentials and minimising them whenever possible.’ Understanding power As a service user who became a trainee clinical psychologist I initially found myself explaining to mental health rights campaigners that I had “defected” to the other side. I was unwittingly widening the “them and us” divide that I had tried to diminish as a service user. Politically things are happening to tackle social exclusion and some brilliant examples of people being included are beginning to be reported … However, I wonder how far political notions have permeated down to effect what happens in 1:1 therapy situations. I have ideas about what people should be able to expect, particularly in terms of bridging the gap and power dynamic that certainly exists as soon as the professional picks up the casenotes or the service user hears about the referral to psychology. I say the power imbalance is a certainty as the psychologist is imbued with the duty of “fixing” or removing the problem from the client who may see themselves as a passive recipients or even victim … have found it helpful to acknowledge difference and maintain curiosity about it, for example by asking people what their explanations of their distress mean on a day-to-day or spiritual level. I wrote a paper with Ron Coleman about whether professionals and service users can really work in partnership given power differences (Coleman & Harding, 2004) and I concluded that even if it seems impossible it should be attempted as we can only improve practice in our efforts. Without conducting a huge survey it is difficult to examine the reality but I believe service users should expect to be regarded with respect and be empowered to define their own outcomes. After all psychologists should be aware of the “power” they may be ascribed and be skilled in enabling their clients to recognise theirs. Emma Harding – taken from Hayward et al., 2007 (p.27–28) For more information please contact Emma Harding, Trainee Clinical Psychologist; e-mail: [email protected]

Reflections from a service user perspective I have found myself at odds with psychologists and other therapists at times simply because I had views and expectations of what I wanted and hoped for from mental health services. A particularly stark example involved a psychologist who did not listen to what I was saying and what I was hoping for from therapy. There was a six-week programme to get through and that was all that seemed to matter. I tried to communicate that the approach was not meeting my needs but the response implied that this was part of the problem that we were trying to address! There was no suggestion that the lack of success was due to anything but my own inadequacies. The experience left me feeling that I was a hopeless case. It took a long time for me to get over this and understand that I was not a failure but an individual needing a collaborative approach to understand and address my difficulties which was based on my own experiences, values, strengths and aspirations. It fills me with

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encouragement to know that this is viewed as a legitimate approach by some therapists but there is still a long way to go before it is seen as the natural way to approach psychological input.

Essential shared capability 4: Challenging inequality ‘Demonstrate an understanding of people with mental health problems, particularly as this relates to access to community inclusion. This includes recognition of the feelings of distress and shame that can be caused by discrimination and how negative reputations can develop and be sustained, and how they can be dismantled’. Raising awareness in schools In North London, then trainee clinical psychologist Catherine Sholl conducted a four-session intervention at a secondary school to change discriminatory attitudes and beliefs about mental health. Catherine co-facilitated the sessions with Juan Korkie, a clinical psychologist and service user. Although primarily a qualitative study exploring the process of changing attitudes, there were positive changes on measures of negative and stereotypical attitudes. The pupils commented on how much they had enjoyed the sessions and learnt from them. Specific attitude and behaviour change included a reduction of fear and social distance, and increases in empathy and a desire to help. The pupils particularly liked meeting the person with experience of using services and would have liked to meet others particularly service users of a similar age to them. For more information please contact Dr Catherine Sholl, Clinical Psychologist; e-mail: [email protected] Raising political awareness Based in East London, Dave Harper helped to facilitate the Critical Mental Health Forum which originally met at the YMCA in Central London. The forum was a joint campaigning and discussion group of mental health service users and survivors, professionals, academics and others who were critical of current theory and practice in mental health services. As well as a forum for political discussion and action the meetings were also social events that ended informally. The forum organised a demonstration outside the Department of Health in August 2002 about the Mental Health Bill and forum members participated in the No Force rally against the Bill in September 2002. Dave comments: ‘There is a need for psychologists to move beyond a focus on the individual and to work with groups of people. This work required me and others to step out of narrow professional boundaries (in terms of models or interventions) in order to work effectively and collaboratively and that obviously requires you to have spent time earning the trust of collaborators. Recognising power differentials should imply more than simply acknowledging it in, say, individual therapy, but involves seeking to try to change society so that barriers to recovery are removed. For each political demonstration we’d set up time-limited task-focused work groups who met at

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members’ flats to plan, make placards, etc. In addition, the forum debated and then submitted responses to government consultations on the reform of the Mental Health Act and on social exclusion and mental health. Notes of previous meetings and details of forthcoming meetings can be found at http://www.critpsynet.freeuk.com/criticalmentalhealth.htm.’ For more information please contact David Harper, Consultant Clinical Psychologist, Reader in Clinical Psychology University of East London - [email protected]

Reflections from a service user perspective There have been numerous anti stigma campaigns in an attempt to reduce the prejudice and discrimination faced by people with serious mental health problems. Yet, if you talk to service users, you will still hear many examples of prejudice and exclusion: you don’t get an interview for a job you are qualified to do, your child doesn’t get invited to other children’s houses, your neighbours ignore you. There are robust measures against racism, sexism, homophobia and, to a lesser extent, ‘disabilism’. Yet the prejudice that people with mental health difficulties face, although a little more subtle than a few years ago, is still rife and mostly goes unchallenged. The simple fact that you can be detained against your will and forcibly treated makes it difficult to feel equal to other people. Mostly, staff have to work with these impediments, sometimes with unease. If we have mental health professionals on our side, understanding what the inequalities are and how they affect us, this will strengthen our demands to be truly equal as citizens. The experiences and testimonies of mental health service users need to be believed and heeded. We need to continue to fight for the rights and respect enjoyed by other members of society.

Essential shared capability 5: Promoting recovery ‘Exercise a hopeful and optimistic approach both towards service users (recovery and social inclusion is within the reach of everyone) and communities (discrimination can be overcome, opportunities for participation can be found or created, other citizens can offer a respectful welcome).’ Individual psychotherapy In Hampshire, clinical psychologists working in an adult acute inpatient care unit use a recovery orientated approach to individual therapy. This work utilises the skills of negotiating collaborative formulations leading to practical ways out of stuck patterns. This includes working on re-integration into the community and the skills necessary for this; addressing problems in important relationships, sometimes by joint therapeutic sessions with partners and liaison with other mental health workers to take this forward. Almost all reports written about people are copied to them. Often the psychologists go through the report with the individual to check that it feels alright before sending it to the consultant psychiatrist and in-patient and community teams.

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Isabel Clarke comments: ‘When working with psychotic experiences, our approach is designed to reduce stigma and introduce an alternative, normalising framework for understanding anomalous experiences, both through a group programme, cofacilitated with nursing staff, and in our individual work. This is in line with research that shows that a non-pathologising frame of reference aids assimilation of such experiences without distress and therefore promotes recovery.’ For more information please contact Isabel Clarke, Consultant Clinical Psychologist; e-mail: [email protected] Recovery Groups In Bromley, Alison Mulligan is involved in developing recovery groups. In the past she has acted as a facilitator and currently she offers supervision and a supportive space to the service user and health care professionals that co-facilitate the groups. Alongside psychology colleagues, service users and local organisations who support and promote recovery (Anthony, 1995), Alison has contributed to the creation of structures which support service user involvement in decision making – for example, by ensuring that service users are involved at every stage in the planning, facilitation and organisation of local recovery groups as well as events to review and evaluate the groups at cross-organisational away days. For more details please contact Dr Alison Mulligan, Clinical Psychologist; e-mail: [email protected]

Reflections from a service user perspective So much mental health care has been aimed at eliminating symptoms and putting service users in a passive recipient role. This is slowly changing but it needs both mental health professionals and service users to think and behave differently. Sometimes ‘choices’ are presented which are not choices: the real choice is to accept what’s on offer or don’t. I was craving help to assist me with what I was thinking and feeling, yet all I heard from professionals was about the severity of my illness, the need to take medication and that I should not work. Service users repeatedly say that we want help to understand our unusual but personal thoughts and experiences. Often these experiences reflect some very important, individual issues which we need help to work through. Although unusual experiences can be quite frightening, especially at first, they feel very fundamental and indeed special to you as a person. I was turned down for psychotherapy as it was felt it would be too stressful for me and might provoke a relapse. Although I accepted this at the time, I now believe that a sensitive, safe environment for me to talk about, understand and come to terms with my internal life would have been enormously healing and empowering.

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Essential shared capability 6: Identifying people’s needs and strengths ‘Carry out or contribute to a systematic, whole systems assessment that has, as its focus, the strengths and needs of the service user and the family and friends who support them.’ Working with families In Wandsworth, clinical psychologists have initiated and led the development of a multidisciplinary family therapy clinic offered to adults in acute inpatient settings. The clinic team consists of both community and ward staff helping to provide a seamless service and continuity of service provision for the service users and carers. The Director of the Trust’s Family Therapy Service provides supervision. The aims of the service are to: ■

work with patients, their families and professional networks in promoting recovery and maintaining the well-being and mental health of the service user when returning to the community;

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provide service users and their families an opportunity to think about the impact of admission;

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reflect on individual strengths of each family member and explore how each person’s strengths can be used to enhance the family’s ability to solve problems;

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help families identify helpful ways of dealing with the specific problems that they meet and to help family members look after their own needs as well as each other’s needs during this stressful time; and

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develop and enhance the family working skills of ward staff with the aim that the ward staff will use these skills outside of the clinic.

Preliminary evaluation has found that service users from a range of ethnic backgrounds, presenting with a range of diagnoses and difficulties had used the family clinic well. The advantage of placing the clinic on the ward was that the clinic team had seen many service users and carers who had never been considered for a family intervention. The use of a consultation model meant that sessions were individually tailored to the family’s needs. Some families had gone on to formal family therapy or engaged in family work with their community care co-ordinator supported by the Clinic Team. For more information please contact Nicolette de Villiers, Clinical Psychologist; e-mail: [email protected]

Reflections from a service user perspective As service users, we are all too aware of the impact our problems can have on those around us. I know that I caused my parents untold distress and that is something I’ll always have to live with. They were very caring yet viewed me as a problem in that they worried about me and saw me in terms of needing to be looked after. This situation was not good for me or them. I felt stifled and guilty and as a result detached myself from my family which in turn caused them more worry, and so on, in a vicious circle. Families often need help but either don’t get it or, for particular reasons, don’t ask for it or want it. It is not uncommon to hear how interventions with the family by mental health services have caused all sorts of 14

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difficulties. Sensitivity and time is required to get to know and understand each family. Families need to know that the mental health services are not going to judge them and are interested in them as a unique entity. A range of approaches will be needed for different families at various times. The focus should be on helping the family and the person experiencing mental distress to understand what is happening, and to agree with the whole family how they can move forward. The value and positive contribution of every member of the family should be emphasised.

Essential shared capability 7: Providing service user centred care ‘Negotiate achievable and meaningful goals; primarily from the perspective of service users and their families.’ ‘Assist service users to transfer from the formal support of a mental health worker to the natural support of reciprocal and informal relationships with people from their local community.’ Individual psychotherapy John Hanna, Consultant Clinical Psychologist comments: ‘Those people with the greatest difficulty in establishing and maintaining healthy interpersonal relationships and/or a positive sense of self-defined purpose in their lives (e.g. through workrelated activity) are thought to be those most likely to be socially excluded in society. When these factors are recognised through the development of a collaborative formulation, then interventions can, and must, aim to address these particular difficulties in order to promote inclusion. The psychological components of a socially included life are, therefore, optimal satisfaction with inter-relatedness and achieving a sense of purpose.’ The case example below illustrates the importance of identifying and negotiating achievable and personally meaningful goals to enable service users to participate in their communities and within the workplace. Case example Bob was referred to see the team psychologist. He had been depressed and isolative for many months, and although his mental health was stable in that he posed no risk to himself, he was terribly unhappy. He had met many times with the team’s occupational therapist and had considered numerous options related to getting back to work and making new friends, but Bob and the occupational therapist realised that he was simply not ready to meet any new challenges despite recognising the good this would do for him. Bob felt increasingly stuck and hopeless. Working with the psychologist, Bob learned why he felt so ambivalent about socialising and taking on new projects. He discovered that his past experiences in relationships had felt mainly neglectful or abusive, and that he had formed a view that anyone with whom he became close would reject or abandon him. He also realised that his efforts to achieve goals had, in the past, produced less than successful results, and that he tended to quit before he finished new projects, if he started at all. With the support of his team, he began to set smaller, less ambitious goals and to spend time noting his achievements when these goals were met. He challenged his avoidant

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tendencies and took more positive risks. As he found relative success in meeting his goals, he became more confident, more aware of when he needed to challenge his self-defeating thoughts and more accepting of obstacles and frustrations. Gradually, he began to feel more socially connected through his efforts, and his week began to fill with manageable, constructive activity which lent a sense of purpose and citizenship to his life. As he developed his identity through a positive work-related role, he had more to say for himself with his mates, and as he gained the support of people on his training course and in his neighbourhood, he found he could try harder to achieve his ambitions. In time, Bob felt he had become what he always hoped he would be, a man with a useful role to play in his community and with a strong circle of friends who offered each other mutual support. Now Bob rarely feels depressed, and when alone enjoys solitude, rather than feeling lonely and unfulfilled. For more information please contact Dr John Hanna, Consultant Clinical Psychologist; e-mail: [email protected]

Reflections from a service user perspective It is true that mental health services can foster dependence. In some ways it is inevitable when you are so in need of help you just need to be told what to do and looked after. However, even if this is the case for a while, it is only a temporary situation. I remember telling my primary nurse that the current regime of hospitalisation, medication and going to OT was not helping me. In fact it was having a detrimental effect. She asked me what would help. I had no idea. That was the end of the conversation, the implication being that there was nothing else. There was no attempt at a dialogue to try and work something out together. Another time a new enthusiastic junior doctor wanted me to have Section 17 leave from hospital to start voluntary work. There was no way I could have done this at that time due to a whole raft of reasons: lack of confidence, shame, apathy, drowsiness, institutionalisation. This was the end of another conversation: I had failed again. No-one was really listening and, crucially, taking on board what I was saying. I think many of their actions and words were well meant but they completely missed the point. What I needed was someone to spend some time with me, to get to know me and to try and work out a way forward that I was comfortable with and had control over.

Essential shared capability 8: Making a difference ‘Utilise a thorough knowledge of how to become involved in community life and how relationships are built and maintained.’ ‘Recognise the healthy and inclusive elements of a service user’s current life and help them to sustain these.’ Existing valued roles Over the past five years I have been involved in developing and delivering recovery-based training workshop for mental health workers from a variety of backgrounds. The workshops focus upon the experience of psychosis and place a significant emphasis on

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practices that facilitate (e.g. seeking to understand the socially derived meaning of psychotic experiences) and prohibit (e.g. hopeless and negative expectations) inclusion. During one workshop I was exploring issues of employment with workers from an inpatient unit. What struck these workers was their neglect of employment as a possible vehicle for recovery. Not so much exploring future employment opportunities, as this may be difficult to do when someone is very distressed. But assessing the impact of hospital admission on existing employment – did employers need to be contacted, sick certificates arranged, etc.? The staff had been operating under the assumption that individuals admitted to the ward were unemployed, and the workshop assisted them to examine this assumption and recognise the role they could play in assisting people to maintain employment as part of a process of remaining connected with valued activity and existing networks. They vowed to introduce an ‘employment’ section to their initial assessment process. For more information, please contact Dr Mark Hayward, Clinical Psychologist; e-mail: [email protected]

Reflections from a service user perspective As mentioned previously, employment, usually the lack of it, is a major issue for service users. A strong emphasis on helping people to retain their employment in the first place as well as assistance to get back into working life is required. I insisted that I wanted to go back to work but was discouraged from doing so. Eventually I was forced to retire through ill health and told that I would never work again. I can only describe it as heartbreaking to be written off in this way. Because I was so insistent about my desire to work, I was referred for “vocational guidance” which consisted of nothing more onerous than watering plants and doing photocopying. After three weeks I left and started some voluntary work. This was the start of a long and arduous process requiring perseverance and creativity to resurrect my working life. Whilst there are some initiatives designed to help service users obtain, and sometimes retain, employment these are piecemeal and offer a limited range of opportunities usually at quite a low level. There is still a tacit assumption that people with serious mental health problems are not capable of holding down a job and certainly not one that requires skill or responsibility. This needs to change. People should not be forced into work when they just can’t cope with it and some people would prefer a job that is not too demanding. This is personal choice and individual circumstances. However, we do need to get away from seeing service users as simply requiring “occupation” but as people with life goals and career aspirations.

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Essential shared capability 9: Promoting safety and positive risk taking ‘Acknowledge and respond to the trauma and distress caused by exclusion. Include “risk of exclusion” in risk assessments by ensuring that risk assessments are hopeful rather than pessimistic, informed by the service user’s ambitions and increase rather than decrease opportunities for recovery and a valued lifestyle. In this way the principle of the “least restrictive alternative” is complimented with the ‘most inclusive alternative.’ Risk taking in context An unemployed man in his late fifties was admitted to an acute mental health unit after making an attempt to end his life. After a few days in the unit, he revealed to staff that he hoped to attend a previously arranged job interview, set for a few days hence. He remained ambivalent about carrying on with his life, but explained to staff that he worried he would further lose hope if he did not keep his commitment to interview for the job, as the interview had been arranged by a former work colleague. His clinical team members were concerned about his ongoing risk to himself when under his own care, especially if the job interview did not go well. But they were also aware that he might become more distressed if he were deprived of the opportunity to attend the interview. The team negotiated a careful risk management plan with the man, and allowed him to attend the interview. He did not get the job, but returned to the ward safely, stating he was grateful for the chance to plan for his future. Dr Dominic Bishop, Specialty Registrar in General Adult Psychiatry For more information please contact: Dr John Hanna, Consultant Clinical Psychologist; e-mail: [email protected]

Reflections from a service user perspective My experience of risk management has been either overly prescriptive and restrictive or woefully inadequate. I have found myself being told not to do things that were important to me such as going back to work, to stopping depot injections and having children. On the other hand, my life and health has been put in danger because of lack of communication, misjudgements and poor care planning and follow up. There seems to be a current mantra in mental health policy that safety should underpin good quality care. However, “risks” and “risk assessments” are mostly negative concepts to service users, associated with restriction and stigma: “risk” implies dangerousness or neglect. It feels an inappropriate and indeed harmful term to use in the context of care and in particular with people with mental health problems who already suffer stigma. The emphasis of risk plans, where present, is usually about preventing a particular behaviour and outlining how this behaviour can be avoided. Although there is sometimes talk about “positive risk taking” it seems a difficult concept to actually put in practice even though the concept is something people in general do as part of their daily lives. Although the terminology and approach to “risk” is dubious, some of the issues that can arise in the process are not. The challenge is how to perceive and implement risk management in a way that is accessible, helps rather hinders and does not perpetuate stigma.

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Essential shared capability 10: Personal development and learning ‘Keeping up-to-date with changes in practice and participating in life-long learning, personal and professional development for one's self and colleagues through supervision, appraisal and reflective practice.’ ‘In order to meet this capability practitioners will need a personal/professional development plan that takes account of their hopes and aspirations that is reviewed annually.’ Reflective practice Sophie Mayhew comments: ‘In my clinical work with clients with severe, complex or enduring mental health problems I use a recovery focused approach and aim to create a safe space for personal exploration and the gathering of information. I work with staff both in a consultancy role and in supervision and training, to enhance their awareness of a recovery focused approach and help negotiating opportunities and appropriate interdependence for clients I work with, particularly those in residential settings. I set up a dedicated monthly group with residential staff to facilitate discussion of client related issues and to help staff think psychologically and in a recovery focused and socially inclusive way about their residents.’ For more information please contact Dr Sophie Mayhew, Consultant Clinical Psychologist; e-mail: [email protected]

Reflections from a service user perspective I have recently been involved in some user-led research, interviewing other service users about recovery in mental health. The interviewees described a service within which staff provided a range of support, e.g. taking service users out on trips, reminding them to take medication, helping people do housework, encouraging them to take up a hobby or even voluntary work and providing advice and a sympathetic ear. The service users were happy with the service and the staff felt they were doing a good job. Yet when you began to unpick the relationship between the staff and the service users, it emerged that much of the impetus and control came from the staff. Very little came from the service users themselves. When you asked the service users about the future, few described aspirations, hope or fulfilment. There was just vagueness, passivity and a little fear. One or two dissenting voices said they did not feel in control of their lives and that they couldn’t envisage leading a normal life. To work with an ethos of empowerment and self determination is not easy, and can be quite frightening, for both service users and staff. Simply encouraging and supporting service users to do more for themselves and to take part in community activities is not sufficient to achieve a meaningful socially inclusive recovery based approach. It was clear that the staff working in the service needed ongoing development to help them understand the, often very subtle, power relationships between mental health workers and service users and to create a more empowering ethos, so vital if service users are to lead fulfilling lives. This could be partly achieved through having service users involved in the supervision and mentoring of staff.

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Section 3 Assessing the inclusiveness of services and practice What follows is a series of questions and prompts to assist the reader in reflecting upon and assessing the inclusiveness of the service that is offered by the individual clinician and/or the multidisciplinary team. Inclusiveness is considered with respect to access to services and the building of capacity for supporting inclusion within communities. An attempt has been made to place these in a logical progression; however, applied psychologists will vary in their circumstances, characteristics and relationship with local communities in which they seek to serve. Thus these prompts should not be viewed as prescriptive, nor necessarily strictly sequential. Organisational and Service objectives 1.

Does your organisation have any explicit policies or a mission statement around improving access to services for minority and disadvantaged groups in your local community, or people who may be excluded from services due to the diagnostic label they have been given? Is there any guidance about working with community representatives (employers, leaders of faith communities, educationalists, etc.) to build capacity to support inclusion through valued social roles and activities? Are you familiar with these and clear about your own role in implementing these? If your service does not have such policies, should you initiate processes within your organisation to create these?

Demographic audit 2.

Are you aware of the demographics of your local/geographic community, i.e. in terms of ethnic, religious, gender, sexual orientation and identity, numbers of refugees and other transitory populations, age and socio-economic representation and levels of physical and psychological disability, and the relative incidence or proportions of these? Most Trusts, local authorities and in particular PCT public health departments have staff whose remit it is to collate and disseminate this type of information. Do you know who has this role in your organisation or an adjacent organisation? Such officers should also be helpful in identifying and making contact with community representatives in relation to these demographic groups (see below).

3.

How well do the clients within your service(s) correspond with the representation of these demographic groups in your local/geographic community (taking reasonable account of the circumscribed nature of the services offered, e.g. older adults)? You may need to conduct an audit of cases to clarify this. Are there any significant discrepancies that cannot be explained by planned boundaries to your service (e.g., women only services) or are services being provided in the private or voluntary sector that meets the mental health needs of specific groups of people?

4.

Consider and reflect upon the reasons for any discrepancies. Is there any aspect of your service that is culturally insensitive or discriminatory? Are there organisational, cultural and/or structural obstacles to inclusion? Do your services seek to encourage

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people with disabilities to attend (e.g. disabled access, information in Braille, public notices in different languages, etc)? 5.

If appropriate, set up a working group with representation from the local community to investigate any discrepancies. Develop an action plan, in collaboration with representatives of the target group to investigate and address accessibility of services. Obstacles to access are often not just physical and practical, but also due to cultural incompatibility and incongruence. The working group could generate imaginative strategies to overcome cultural obstacles, which are relevant and appropriate to local circumstances.

6.

Seek independent views. Employ service user and carer consultants to survey minority clients who do access your service about their experiences, both positive and negative. Who defines the outcomes that are valued and pursued by your service? Are they consistent with the outcomes and goals desired by clients and their carers? What happens to people who do not attend the service at all or terminate their care plan prematurely?

7.

Are you able to find out what proportion, compared to the general population, of people who use your services, are in work, education, live in valued accommodation, have extended social networks, are active in the arts, culture, faith, volunteering and leisure activities?

Inclusion of belief systems and world-view into clinical work and service culture 8.

Are you and your service able to routinely consider and assess the client’s world-view, religious orientation (if any) and its relevance (or otherwise) to formulation and intervention? How can your service demonstrate respect for the full range of religious, cultural, personal belief systems and world-views?

9.

Do you include the client’s specific community context (religious/cultural/extended family, etc.) as a potential asset in planning intervention and as a means of assisting with intervention? Some people might choose not to be included in their communities, perhaps because of discriminatory past experiences.

10.

Do you have good contacts with local religious leaders, employers, educationalists, peer groups etc. who might collaborate with you in your intervention (if appropriate)? Are you open to religious, spiritual and cultural perspectives on psychological difficulties and willing to engage with these?

Community contact and engagement 11.

How can contact with and engagement of local community leaders and groups become a valued activity for your service?

12.

How can local community views of mental health problems influence the practice and delivery of services?

13.

To what extent are the skills, experience and demographics of the local service workforce representative of the population that is served? It does not follow that services will be inclusive even if service staff ‘match’ their local population in some defined way. Are service users and carers actively involved in the development and delivery of the service offered? ‘

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Looking ahead Social inclusion is such a wide ranging and flexible notion that it affords a great opportunity for human services to work more holistically with individuals, groups and indeed with whole communities. Many believe that it is imperative for its success that it does all three. The recent work on beginning to address deep exclusion by working with whole families (SETF, 2008) and using systemic approaches to building community capacity in mainstream institutions (e.g. NSIP, 2008) shows that although the social inclusion agenda is now more than ten years old there is still a great deal more to do. Such a distance travelled and yet so far to go. The BPS, as the supporting structure for applied psychologists in the UK, therefore has begun to take a broad responsibility to sponsor, stimulate and oversee a range of involvements for the profession at different levels and in different arenas as this continuing area of growth in public policy begins to mature. To this end the Professional Practice Board has taken a number of steps forward in the past year, including the publication of this initial paper. As the result of a cross-divisional seminar held in October 2007 three work streams have been agreed and are being supported through the secondment of a Faculty Chair to NSIP to work on community engagement. The Society’s work streams are about the lives and well-being of children and families, offenders in prison and peoples’ return to employment. This work will be linked directly to continuing developmental work within NSIP, the Department for Work and Pensions, Sure Start and the SETF and will be monitored by the PPB on behalf of the Society. For further details about the next steps please contact Nigel Atter (Policy Advisor; e-mail: [email protected]) or visit http://www.bps.org.uk/the-society/organisation-andgovernance/professional-practice-board/ppb-activities/social-inclusion/ social-inclusion_home.cfm

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References Anthony, W.A. (1995). Recovery from mental illness: The new vision of services and researchers. Innovation & Research, 1, 1, 13–15. Care Services Improvement Partnership (2007). Capabilities for inclusive practice. London: Department of Health. Coleman, R. & Harding, E. (2004). Can we really be partners. Mental Health Nursing, September. Davis, F.A., Hankinson, N., & Morris, D. (2008). Communities of influence. Available from National Social Inclusion Programme, 11–13 Cavendish Square, London W1G 0AN. Davis, F. & Turpin, G. (2004). DCP evidence presented to the Social Exclusion Unit’s enquiry into Social Exclusion and Mental Health. Leicester: British Psychological Society. Division of Clinical Psychology (1995). Professional practice guidelines. Leicester: BPS. Hayward, M., Brown, M., May, R. & Harding, E. (2007). Social inclusion and clinical psychology. Life in the Day, 11, 27–30. Hope, R. (2004). The ten essential shared capabilities: A framework for the whole of the mental health workforce. London: Department of Health. Mental Health Europe (2008). From exclusion to inclusion: The way forward to promoting the social inclusion of people with mental health problems in Europe. Accessed on 18th May 2008 from http://www.mhe-sme.org/assets/files/ From%20Exclusion%20to%20Inclusion-Final%20version.pdf National Social Inclusion Programme (2007). National Social Inclusion Programme third annual update. http://www.socialinclusion.org.uk/publications/NSIP32007.pdf Office of the Deputy Prime Minister. (2004). Mental health and social exclusion. Wetherby: ODPM Publication. Onyett, S. (2007). New ways of working for applied psychologists in health and social care: Working psychologically in teams. Leicester: BPS. Orford, J. (2008). Community psychology: Challenges, controversies and emerging consensus. Chichester: Wiley. Social Exclusion Task Force (2006). Reaching out: An action plan on social exclusion. London: Cabinet Office. Social Exclusion Task Force (2008). Think family: Improving the life chances of families at risk. London: Cabinet Office. Vassallo, T. (1998). Narrative group therapy with the seriously mentally ill: A case study. New Zealand Journal of Family Therapy, 19(1), 15–26.

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The British Psychological Society was founded in 1901 and incorporated by Royal Charter in 1965. Our principal object is to promote the advancement and diffusion of a knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of Members of the Society by setting up a high standard of professional education and knowledge. The Society has more than 46,000 members and: ■ has offices in England, Northern Ireland, Scotland and Wales; ■ accredits undergraduate programmes at 117 university departments; ■ accredits 143 postgraduate programmes at 84 university departments; ■ confers Fellowships for distinguished achievements; ■ confers Chartered Status on professionally qualified psychologists; ■ awards grants to support research and scholarship; ■ publishes 11 scientific journals, and also jointly publishes Evidence Based Mental Health with the British Medical Association and the Royal College of Psychiatrists; ■ publishes books in partnership with Blackwells; ■ publishes The Psychologist each month; ■ supports the recruitment of psychologists through the Psychologist Appointments section of The Psychologist, and www.psychapp.co.uk; ■ provides a free ‘Research Digest’ by e-mail and at www.bps-researchdigest.blogspot.com, primarily aimed at school and university students; ■ publishes newsletters for its constituent groups; ■ maintains a website (www.bps.org.uk); ■ has international links with psychological societies and associations throughout the world;

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provides a service for the news media and the public; has an Ethics Committee and provides service to the Professional Conduct Board; maintains a Register of nearly 15,000 Chartered Psychologists; prepares policy statements and responses to government consultations; holds conferences, workshops, continuing professional development and training events; recognises distinguished contributions to psychological science and practice through individual awards and honours.

The Society continues to work to enhance: ■ recruitment – the target is 50,000 members; ■ services to members – by responding to needs; ■ public understanding of psychology – addressed by regular media activity and outreach events; ■ influence on public policy – through the work of its Policy Support Unit, Boards and Parliamentary Officer; ■ membership activities – to fully utilise the strengths and diversity of the Society membership; ■ operates a Psychological Testing Centre which sets, promotes and maintains standards in testing.

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REP59/09.2008