RURAL EMOTIONAL SUPPORT TEAM: Working with Dispersed Populations

1. RURAL EMOTIONAL SUPPORT TEAM: Working with Dispersed Populations Tom Dodd Chair REST National Lead Dual Diagnosis & Community Teams, CSIP

2. Living in a place like this really is good for you BBC Jan 2006

3. Access to appropriate services can be problematic for those in remote areas • The further people are from a service the less likely they are to use it. • Many of the highest risk professions for suicide rates are related to agriculture - farmers, rural vets, stable workers • Incidences of stigma and discrimination are often high in rural areas • Cultural and geographical factors mean that the extent of mental health problems in the countryside is likely to be hidden - both unreported and undiagnosed. • Richard Brook, Mind (2006) commenting on Rural/non-rural differences in rates of common mental disorders in Britain (Weich et al) The British Journal of Psychiatry (2006) 188: 51-57. doi: 10.1192/bjp.bp.105.008714

4. The effect of geography is a very modest one, but the main factors are likely to be social - especially interpersonal relationships and perceptions of safety. Quantifying between-place differences using population density alone risks missing important contextual effects on mental health.

5. Geographies of Care • Both users and service providers recognise that it ismore difficult to provide a comprehensive mental health service in a rural region than in an urban one. Many feel that models of provision from urban centres are inappropriate in a rural context, not least because of the distances that have to be travelled. Psychiatrists are seen as reluctant to travel to the more remote areas andGPs are therefore expected to deal with problems for which they lack training.   • Users admit toavoiding accessing services until they are 'in crisis'due to the fear that their problems will become known to the wider community.

6. Geographies of Care • Users particularly value the contribution of Community Psychiatric Nurses (CPNs), not so much because of their assistance with medication, more because they are ready and able to talk at length about someone's mental health problems in a way that family, friends and neighbours in this region often find difficult. • Despite not wanting the wider community to know of their condition, users report a sense of community at drop-in centres. Research suggest that such centres could play an important role in changing attitudes to mental health in rural communities. • In the region studied there was evidence that some users are migrating to larger settlements in order to remain relatively anonymous in accessing services.  Rural Mental Health: inclusion and exclusion in the Scottish Highlands Philo & Parr, 2003 

7. The lack of formal 'places of safety' to which people in rural and remote areas can go during acute phases of illness was of great concern to those interviewed. • Whether people are 'local' or 'incomers' can also shape the response of the community to mental illness. And the relative acceptability of alcohol misuse in rural communities means that drink is frequently used as a cover for mental health problems.

8. The report urges development of more collective support services through statutory or voluntary organisations, improved transport links, and more specialists available with whom people can talk through their problems. • It says special clinics based in GP practices in local areas, involving psychologists, counsellors and psychiatrists, would both improve support services and ease transport difficulties.

9. Values Your values exist as a complex set of interweaving personal policies or priorities that serve as a guide for decision making

10. Values • Knowledge based values – I value philosophy because it gives me great insights • Aesthetic based values – I prefer old masters art to modern art • Instrumental values – I must have a job to achieve extrinsic goals • Moral values – I believe it’s wrong to lie because it shows disrespect • Personal preference based values – love curry, hate sprouts Adapted from Ursery, D

11. Community Infrastructure Values • Veterinary services • Church • NFU • Banks • Parish Networks • Feed & Machinery Suppliers • Family • Other farmers • Health services • Social services • DEFRA • Benefit agencies • ‘Outsiders’ • Trading Standards • Police • Council & Planning

12. Personal Values of REST clients • Privacy and dignity • Self reliance • Work ethic • Drive to appear successful • Financial independence • Respect derives from value/usefulness • Aversion to issues of bureaucracy and power

13. Personal Values of REST clients • Work and private life are interdependent • Mental health issues are seen as weaknesses and a failure • Own health is often secondary to health of livestock • Distrusting of systems outside of the context of daily life

14. How do these values translate into practice? • Flexibility around working hours • Presentation and language • Terminology • Engagement – demonstrating practical worth • Positive risk taking • Location • Community allies • Review of protocol and practice guidelines • Challenge to information sharing

15. How do these values translate into practice? • Linking skills and experience to values and need • Capability more important than ‘professional’ titles • Strengths and solutions • Involving the family (sensitivity about social supports, other workers) • If you say you’re going to do something – do it! Building respect and trust • Work within a system of resources that make sense to the client

16. Value Conflicts and Dilemmas • When values conflict, choices must be made • Prioritising – reveals our primary value in making a moral judgement (our core values) • Some values are goals, others how we should act to achieve them • Setting priorities often leads to value conflicts

17. Dilemmas which had to be worked through… • Language • Appearance • Community confidence • Mutual respect • Local Knowledge - an appreciation of the realities of farming • Working as a whole team • Empathy • Getting your hands dirty • Up to date knowledge of agricultural policy and paperwork

18. Integrity is a much used, but barely understood, concept - in respect of both individuals and communities. It involves continual reflection on the values you live by, and on the rules or actions intended to express those values. Roger Sutcliffe, Director of DialogueWorks & Vice-Chair of Britain’s Values Education Council The test of ethical competency is the extent to which people can be trusted to act in accordance with their organisation’s self-imposed values that are not enforced by law, even when under extreme pressure.

19. Codes of conduct, value statements, and policies are critical elements in building an ethical consulting practice but they do not assure ethical action when we are confronted with ethical dilemmas real-time and we face immediate internal or external pressure to compromise our ethics and our values. There are no easy answers to some situations that challenge our ethics and our values. But by being mindful of the ethical dimensions of decisions we make, by exploring what is the best course of action, and by taking and owning our actions we are consciously striving for life at work and with our clients that is closer to our ideals. And that is a worthwhile endeavour. Acting Ethically When Our Values Rub Up Against Reality - Jack Gilbert

20. Rural Emotional Support Team, The Grandstand, Staffordshire County Showground, Weston Road, Stafford ST18 0BD. Telephone: 01785 255305 Fax: 01785 255353 email: REST@ruralnet.org.uk Tom.dodd@nimhe.wmids.nhs.uk