Early Intervention in Mental Health Problems: The Role of the Voluntary Sector

CHAPTER 12
Early Intervention in Mental Health Problems: The Role of the Voluntary Sector


Andrew McCulloch, Isabella Goldie and Sophie Bridger


Mental Health Foundation, UK


This chapter attempts to address the role of the voluntary sector [non-government organisations (NGOs) or community managed organisations (CMOs) or sector, private not for profits in the United States] in early intervention in mental health problems.


While acknowledging some very worthy efforts by voluntary organisations elsewhere in the world (e.g. headspace centres in Australia and Headstrong centre in Dublin as consortia partnerships between public and NGO mental health services, drug and alcohol and primary care services to form convenient one stop shops for young people located in their favourite mingling spaces, providing practical help for a wide range of psychosocial disorders), we will concentrate on UK examples as the authors are most familiar with them.


It describes how the voluntary sector in the United Kingdom typically approaches this issue, what sort of solutions and support it offers, what are its strengths and weaknesses, and its future aspirations. The concept of early intervention in the voluntary sector has been fairly widely used since the Melbourne model of early intervention in psychosis was first disseminated in the 1980s by Pat McGorry and others [1]. Whilst most of the teams set up in the United Kingdom have been in the statutory sector, there has been voluntary sector involvement from agencies such as Hafal in Wales and Rethink in England. However, with the currency of the concept of early intervention developing more widely, the use of the term within mental health has become confused and is differently understood to mean:



  1. Early intervention in psychosis following the Australian model;
  2. Early intervention more generally in the course of a disease to prevent it developing, ameliorate it, or cut short its course that is elements of treatment, secondary and tertiary prevention. It is assumed that early intervention in the disease process is by definition distinct from primary prevention although the content of primary prevention and early intervention services/programmes/interventions might not always differ. This is where the real scope for confusion arises;
  3. Early intervention in the life course to prevent mental illness later in life or generational mental illness cycles as may exist in schizophrenia, for example.

Although early intervention in psychosis services are mainly located within the public or statutory sector, where they are practiced within the charitable sector, then without notable exceptions these are operated by specialist mental health organisations. Services which aim to intervene at an early stage in the development of a mental health problem as described in point (b) above are also dominated by the specialist mental health voluntary sector. However, other types of voluntary sector organisations can have a pivotal role to play, for example, in reducing the incidence of the onset of mental health problems later in life such as those offering parenting support. Reducing the prevalence of mental health problems across society may not be an explicit aim of more generic organisations working with children and young people but none the less actions designed to reduce childhood poverty may also impact on some very important determinants of mental illness.


There is an evidence and intellectual base for all three types of intervention but the authors have been able to identify very little literature on early intervention in mental health that has a specific focus on the voluntary sector’s role. We are aware of only one peer reviewed research study, about a parenting intervention, and this study missed the opportunity to look at the relevance of the voluntary sector setting for the work [2]. This chapter has therefore had to be based on anecdotal evidence, grey literature, and systematic information gathered from 11 major charities across the United Kingdom for which we are most grateful.


After providing some key background, this chapter will attempt to:



  1. Group or classify voluntary sector work in this area
  2. Provide some examples
  3. Report on the systematic data collected from 11 charities
  4. Summarise what the voluntary sector may have to offer
  5. Draw these threads together and reflect on future directions and challenges.

In doing so we recognise our view is partial and we hope more data will emerge, as early intervention moves from a concept which is theoretically sound to one with a much more systematic applied research base.


The voluntary sector and mental health


Briefly, what is the history of voluntary sector in the United States and Australia?


The voluntary sector has a long history of delivery in mental health. The Bethlem was founded in 1247 and many modern mental health charities are over 50-years old [3]. In some ways, the bulk of charitable provision on mental health has remained as it always was – focused on care and support for people with severe mental illness. Most of the £1bn or more charitable spend each year on mental health in the United Kingdom is spent on this group of people and is focused on housing and housing support, employment rehabilitation, day care and other services including inpatient care provided by charitable psychiatric hospital providers. Little of this spend is on any service that could be defined as early intervention, and most of it represents NHS or local authority contracts with, or grants to, charities which are trading as limited companies. The voluntary sector is taken here to imply charitable status and although there are other definitions, for example, including friendly societies and mutuals, this is unlikely to affect the overall analysis offered in this chapter.


How the voluntary sector views early intervention


There continues to be confusion in the sector between early intervention in the disease process and early intervention in the life course – the latter is the way the term is currently most often applied by the UK governments. But in this chapter, we will address all early intervention to prevent, treat or ameliorate mental illness (i.e. primary, secondary and tertiary prevention) regardless of when it comes in the lifespan (pre-birth to old age). Conceptually, age-related definitions of early intervention are not really relevant to many of the risk factors which impact on mental ill health as many are not chronologically determined or may be additive or be involved in dynamic interactions throughout life. Therefore, it makes little sense in this context to regard age three as a cut-off for ‘early intervention’ and most voluntary organisations in our experience would share this view.


Whilst there is little literature on the subject we would observe that voluntary sector colleagues tend to advance an early intervention model for a number of understandable practical, theoretical and in some cases, evidence based, reasons:



  • It is preferable to forestall the development of mental illness for all sorts of reasons – medical, psychological, social and family related – as well as to reduce suffering;
  • Economic and presumed economic advantages both generally and in terms of use of specialist services;
  • Such interventions can build community and social capital and reduce stigma thereby placing the service user into a more supportive environment;
  • Such interventions support recovery and build the user’s capacity to survive and thrive;
  • They can prevent exit from employment and educational opportunities or facilitate rapid re-engagement;
  • They may prevent morbidity, mortality (e.g. from suicide) and comorbidity;
  • They are what both service users want and what charities see as fulfilling their missions which often related to disease reduction and mental health improvement as well as just providing support;
  • They can combat stigma and discrimination.
  • The may prevent or reduce social drift.

There will be others, but it is fair to say that early intervention is generally seen as a presumed good by mental health charities although it is understood that the evidence base is better for some disorders such as schizophrenia and conduct disorder than others; although many would see this simply as the result of a lack of research and service models.


Towards a systematic understanding of early intervention by the voluntary sector


The authors have decided to use Martikainen’s model of the generation of health/illness in order to derive the points of leverage at which early intervention might work. His model is presented in Figure 12.1 and using that model we have attempted to classify early intervention by the point of leverage as against the conceptual framework in Table 12.1.


Table 12.1 Modalities of early intervention in mental health


































(1) Early intervention in psychosis (2) Early intervention in the development of mental illness (3) Early intervention in the life cycle to prevent mental illness and/or improve mental health
(A) Individual biological factors Proactive medication for psychotic illness Proactive medication for other illnesses Physical public health interventions, diet, exercise, maternal health during pregnancy, etc.
(B) Individual psychological factors Proactive psycho-education Ditto, also peer support, self-management, relaxation training; coaching, DBT and CBT and related interventions, etc. Population use of emotional awareness, meditation or cognitive techniques with an emphasis on parents and children
(C) Family-level psychological factors Pro-active family therapy Ditto, also other family-level interventions Parenting education, intergenerational contact interventions
(D) Meso-level factors Anti-stigma and discrimination initiatives at community level Settings-based activities e.g. provision of counselling in schools Wider public mental health interventions in settings – primarily mentally health schools and nurseries, health visiting, family friendly communities
(E) Macro-level factors Anti-stigma and discrimination initiatives, national policy on early intervention teams Ditto Public mental health, tackling inequalities and social drift
images

Figure 12.1 The generation of health and illness. After Martikainen et al. (2002). Reproduced with permission of Oxford University Press


It can immediately be seen that some cells contain interventions which are more amenable to voluntary sector intervention than others, thus there is probably more voluntary sector activity in the last column than the others and more in the row which addresses meso-level factors (factors at community and institutional level) than the rest. This is understandable as most voluntary sector interventions are at a fairly low level in terms of technical content and are often community or setting focused – and none the worse for that, of course. Indeed this is where the greatest gains may be made. The important point however, is that the growth of early intervention by the voluntary sector has been ad hoc and uncoordinated and of course many generic charities do not even see their intervention as primarily mental health relevant.


Case studies


In the following section, we offer some case studies relating to the cells in Table 12.1. where the voluntary sector makes the largest contribution. Arguably these cells are A3, B2, C3, D1 and D2. The types of interventions can be broadly summarised as follows:


Early intervention in the life cycle – individual biological and psychological factors


Typically these interventions are delivered by non-health agencies seeking to implement wider objectives around issues like participation in sport which can deliver a wide range of health and social benefits.


Early intervention in the course of mental illness – individual psychological factors


The voluntary sector has a very specific role here in encouraging, for example, youth work type interventions that build individual self-esteem, peer support and a setting in which care pathways can be accessed early. Offerings like Right here contain elements of this approach along with wider elements (case study in Box 12.4). In recent years, mental health and well-being are often an explicit part of such initiatives and mental health care pathways may be available facilitating most specialist early intervention and treatment services. It is hard to distinguish at the margins between targeted prevention and public mental health services, and early intervention services. However, we are not aware of any ‘pure’ or medically oriented early intervention services run by the voluntary sector although some services run by rethink mental illness, especially Uthink (Box 12.1) may come nearest to this. However, voluntary sector services do provide a range of support and rehabilitative/recovery-oriented services which play an important role alongside statutory sector services. These can, of course, only be seen as part of an early intervention model if referrals are made to them or clients access them early in the progression of mental health problems.

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May 29, 2017 | Posted by in PSYCHIATRY | Comments Off on Early Intervention in Mental Health Problems: The Role of the Voluntary Sector

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