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Young people aged 16 to 25: The promotion of mental health and well-being and the early intervention in mental health problems
Contents Abbreviations 02
Glossary of terms 03
1. Mental health and mental health problems 05 1.1 Mental health and well-being 05 1.2 Mental health problems 05 1.3 The impact of mental health problems on young people 05 1.4 The need for early intervention 05
2. Risk and protective factors and resilience 06 2.1 Risk factors 06 2.2 Protective factors and resilience 06 3. Stigma and discrimination 08 3.1 Multiple discrimination 08 3.2 Tackling stigma and discrimination 08
4. Young people participation 10 4.1 Benefits of participation 10 - Organisations, funders and community 10 - Young people 11 4.2 Challenges to achieving participation 11 4.3 Impact of participation 11
General conclusions 12
BMA British Medical Association CSIP Care Services Improvement Partnership DfES Department for Education and Skills DH Department of Health MHF Mental Health Foundation NIMHE National Institute for Mental Health in England ODPM Office of the Deputy Prime Minister PRT Prison Reform Trust SCMH Sainsbury Centre for Mental Health WHO World Health Organization
Literature Review 03
Glossary of terms
Early intervention In this literature review, early intervention refers to action being taken in the early stages of someone having mental health problems, regardless of their age.
Young people The term ‘young people’ is used to cover different age ranges by different research reports and policies. In this report, the term ‘young people’ refers to 16- to 25-year-olds unless otherwise stated.
Mental health problems
Anxiety Anxiety is a universal human emotion, regarded as a mental health problem when it is severe and persistent.
Depression Depression describes a range of moods, from the low spirits that we all experience, to a severe problem that interferes with everyday life, often referred to as ‘clinical depression’.
Self-harm Self-harm describes a wide range of things that people do to themselves in a deliberate and usually hidden way. In the vast majority of cases, self-harm remains a secret behaviour that can go on for a long time without being discovered. Self-harm can involve cutting, burning, scalding, banging or scratching one’s own body, breaking one’s bones, pulling one’s hair, or ingesting toxic substances or objects.
For further details and information on the above and other mental health problems, issues and treatment options, please go to the Mental Health Foundation’s Mental Health A – Z: www.mentalhealth.org.uk/information/mental-health-a-z/
Introduction This literature review, alongside both practice and policy reviews, is being undertaken to help inform the Right Here programme being developed by the Mental Health Foundation and Paul Hamlyn Foundation. Young people between the ages of 16 to 25 can face a number of major transitions and challenges in their lives. The Right Here programme acknowledges this and aims to increase understanding of how to best promote mental health and develop early intervention in mental health problems during this time of transitions.
The full version of this review is available as a PDF from www.right-here.org.uk
Literature Review 05
1. Mental health and mental health problems
1.1 Mental health and well-being
Mental health and well-being are more than the absence of mental health problems. The WHO (2008a) defines mental health as:
... a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.
Mental health underpins a young person’s development and enables them to form and maintain relationships, and face and cope with problems (MHF and Office of Health Economics, 2005). Keyes (2007) argues that we should see mental health as one continuum and mental illness as another, which means that a person can have poor mental health without being mentally ill, and vice versa. Poorer mental health (“moderate” or “languishing”)1 can lead to increased physical health problems, time off work, more limitations in people’s daily lives and “poorer psychosocial functioning” (Keyes, 2007). To date there has been a greater focus placed on measuring mental health problems than mental health (Mentality, 2003).
1.2 Mental health problems
Data on children and adolescents aged between 5 and 16 has shown that as many as one in ten has a clinically recognisable mental health problem (Green et al, 2005). It is estimated that one in 15 of 11- to 25-year-olds self harm, usually by cutting (MHF and Camelot Foundation, 2006). Alcohol and drug misuse among young people have been identified as a cause for concern, partly because of associated mental health risks (HM Government, 2008; Information Centre, 2007; MHF, 2006a; BMA, 2003). Data on adults has shown that one in six has a mental health problem, with depression and anxiety being the most common problems (Singleton et al, 2001).
1.3 The impact of mental health problems on young people
There are many potential impacts, including poor educational achievement, disruption to family life, and increased risks of becoming homeless, being unemployed and developing physical health problems (SCMH, 2007; MHF, 2006b; DH, 2004; Seymour, 2003). In addition, more young people in prison have mental health problems than adults, and young men aged 15 to 17 in prison were found to be 18 times more likely to commit suicide than men of the same age in the general population (PRT, 2008; Fazel et al, 2005).
1.4 The need for early intervention
There is a growing body of evidence to show that childhood mental health problems are the precursors of adult mental health problems (WHO, 2005; Kessler et al, 2005; Kim-Cohen et al, 2003). Kim-Cohen et al (2003) point out the need for detecting problems in childhood and emphasise the importance of aiming preventative measures “early in life” (Kim-Cohen et al, 2003). Their research indicates that effective treatment of childhood mental health problems may lead to the prevention of mental health problems in adulthood in as many as half of cases (Kim-Cohen et al, 2003).
1. Keyes (2007) places mental health into 3 categories: “flourishing”, “moderate”, and “ languishing”.
2. Risk and protective factors and resilience
It is known that certain factors can impact on mental health and well-being in young people. Factors which have a positive impact are known as protective factors, and those which have a negative impact as risk factors.
2.1 Risk factors
It is known that factors such as poor social networks and poor parenting, among many others, can lower the possibility of a child or young person developing into a mentally healthy adult (MHF, 1999). However, the relationship between risk factors and the outcome for a child is not simple, and while it is more likely that a child will experience poorer outcomes if they are exposed to more risks, the outcome is not inevitable (DfES, 2007).
Newman (2004a) suggests that times of transition, such as those experienced by young people aged 16 to 25, can be both “threats and opportunities”. Support and guidance from families through the transition to adulthood is thought to be important, but not all young people have this, which may leave them vulnerable (Morrow and Richards, 1996). It is argued all that has come before in young people’s lives, whether positive or negative, reaches a peak in the transition to adulthood (ODPM, 2005). Some young people face particular disadvantage or multiple disadvantages (such as being homeless, having mental health problems, being unemployed) and for those, the transition to adulthood can be more complex (ODPM, 2005). Support and guidance that takes into account a young person’s networks and lifestyle is vital at this time for those at risk (MHF, 1999).
2.2 Protective factors and resilience There are some young people who do not develop mental health problems even though it would seem likely given the risk factors. There are protective factors that reduce risk, strengthen mental well-being and increase the possibility of positive outcomes (Jenkins et al, 2002; HM Treasury and DfES, 2007). These factors are thought to increase ‘resilience’, which is defined as: “patterns of positive adaptation or development manifested in the context of adverse experiences” (Masten and Gewirtz, 2006).
Strategies identified as promoting resilience in adolescents and young adults aged 13 to 19 years are:
• strong social support networks
• the presence of at least one unconditionally supportive parent or parent substitute
• a committed mentor or other person from outside the family
• positive school experiences
• a sense of mastery and a belief that one’s own efforts can make a difference
• participation in a range of extra-curricular activities
Literature Review 07
• the capacity to re-frame adversities so that the beneficial as well as the damaging effects are recognised
• the ability – or opportunity – to ‘make a difference’ by helping others or through part-time work
• not to be excessively sheltered from challenging situations that provide opportunities to develop coping skills. (Newman, 2004b)
It is argued that what is needed is a strategic framework that reduces risk factors and increases protective factors and that operates at individual, community and structural levels (DH, 2001; Jenkins et al, 2002). These would involve: “strengthening individuals” (e.g. by increasing emotional resilience); “strengthening communities” (e.g. by increasing social inclusion); and “reducing structural barriers to mental health” (e.g. by reducing discrimination and inequalities) (DH, 2001). Jenkins et al (2002) suggest that these can then be addressed at:
• different stages in life (this could include early adulthood)
• different settings (this could include colleges, youth centres etc.)
• different levels (such as locally, regionally or nationally).
Risk and protective factors and promoting resilience
3. Stigma and discrimination
Stigma and discrimination have been found to be major problems for people with mental health problems; they can help to impede recovery, make symptoms worse and stop people from getting help when they need it (WHO, 2008b). Stigma and discrimination can lead to people with mental health problems being marginalised in society, affecting their quality of life and their ability to participate fully in society. Stigma may also be internalised (self-stigma), as negative attitudes are ‘absorbed’, resulting in a loss of self-esteem and self-worth (WHO, 2008b). Experiencing mental health problems may lead to a cycle of “social exclusion, including unemployment, debt, homelessness and worsening health” (ODPM, 2004).
A recent survey has shown that there is marked lack of public knowledge concerning mental health problems, with 63% of people describing those who are mentally ill as ‘suffering from schizophrenia’ and 56% believing someone mentally ill has to be kept in a psychiatric hospital (TNS for Shift, CSIP, 2007).
3.1 Multiple discrimination
Some people are subject to more than one form of discrimination, such as being discriminated against due to having a mental health problem, and being from a minority ethnic group. There is a current lack of research evidence and knowledge on the impact of multiple discrimination (Thornicroft, 2006).
3.2 Tackling stigma and discrimination
Thornicroft (2006) suggests that the concept of stigma is best seen as three problems, described in detail by the WHO (2008b):
Ignorance: the problem of knowledge. Most people do not know very much about mental health problems, and much of what they do know – or think they know – is inaccurate.
Prejudice: the problem of negative attitudes. People fear and avoid other people with mental health problems; people with mental health problems anticipate and fear avoidance from other people.
Behaviour: the problem of discrimination. People act towards people with mental health problems in ways that are unjust and unfair.
Thornicroft (2006) notes that much of the research to date has been on attitudes, and argues for a stronger focus on discrimination (behaviour rather than intentions) and action to fight social exclusion.
Literature Review 09
The WHO (2008b) states that recent research has indicated that the most effective programmes for long-term change in tackling stigma, discrimination and social exclusion use a number of tactics on different levels. The WHO (2008b) suggests breaking down action plans using the following questions:
• What do you want to achieve?
• Why do you want this outcome?
• When do you want to achieve it?
• How will you go about making it happen?
• Who has the power to make it happen?
• Where are you now and where do you want to be?
One of the most important factors in tackling stigma and discrimination has been found to be direct contact with someone who has experienced mental health problems and who can relate the experience to others (WHO, 2008b; Thornicroft, 2006, Pinfold et al, 2005). Young people participation is recommended in all areas of programme development, including monitoring and evaluation (NIMHE, 2004). Thornicroft (2006) calls for evaluation to support all projects and suggests that they assess positive changes with regard to:
1) knowledge about mental illnesses
2) negative emotions and attitudes towards mentally ill people
3) negative discriminatory behaviour towards people with mental illness.
Stigma and discrimination
4. Young people participation
Research suggests that, whilst there is increasing commitment to young people participation, there is a gap between policy and practice (Carnegie UK Trust, 2007). It is suggested that training and support on participation may be required (Carnegie UK Trust, 2007), plus a greater focus by organisations and services on what changes should be made to their culture, ethos and structure (Kirby et al, 2003; Wright et al, 2006).
There are many ways that young people can participate, from taking part in board meetings to running workshops. Research has shown that several factors facilitate effective participation (Day, 2008; MHF, 2007, Wright et al, 2006, Connexions, 2001) and these are brought together as follows:
• Aims, objective and outcomes that are agreed at the start
• Transparency and honesty particularly with regard to how much young people will be able to influence decisions
• Flexible and creative approaches
• Ensuring the right environment for young people.
4.1 Benefits of Participation
Organisations, funders and the community
According to various sources (Wright et al, 2006; Vasiliou-Theodore and Penketh, 2008; YoungMinds, 2005; Kirby et al, 2003), there are many potential benefits, including:
• organisations becoming more responsive to young people’s needs
• organisations becoming more accessible to young people
• funders being able to see young people’s satisfaction with services
• the community benefiting through young people becoming “active and competent citizens” (Kirby et al, 2003) and “making a positive contribution to society” (YoungMinds, 2005).
There are a diverse range of possible benefits for young people including:
• personal development
• gaining transferable skills
• acquiring communication skills
• influencing change
• raising awareness of young people’s mental health
Literature Review 11
• reducing stigma and discrimination
• giving something back to services (Vasiliou-Theodore and Penketh, 2008)
• having their contribution recognised
• and meeting new people across different age ranges (Kirby, 2004).
4.2 Challenges to achieving participation
There are some important challenges to achieving meaningful participation that include: ensuring sufficient participation from different groups of young people (Connexions, 2001); avoiding tokenism whereby young people have no real voice (Day, 2008; MHF, 2007); committing sufficient time and resources (MHF, 2007); and reducing resistance to participation within organisations (Hasler, 2003; Kirby et al, 2003). Getting young people participation off the ground can take time, as young people may need to build up trust with professionals, groups or organisations (MHF, 2007; YoungMinds, 2005).
4.3 Impact of participation
Research on the impact of participation is limited and there has been a focus on the process - service users’ experiences of participation - rather than outcomes and actual change, such as improvement to the quality of services (Fudge et al, 2008; Carr, 2004).
Young people participation
1. There needs to be an increased focus placed on mental health. This should include further research and measures of young people’s mental health to ensure that their mental health needs are met.
2. It is important to develop early intervention in detecting and treating mental health problems, as well as promoting mental health. The aim of this will be to prevent problems from worsening or becoming embedded.
3. Strategic frameworks for the promotion of mental health and resilience need to operate to strengthen both individuals and communities, and reduce structural barriers to mental health. These can then be addressed at different times (such as early adulthood), in different settings (such as youth centres, colleges and others) and at different levels (such as locally, regionally and nationally).
4. The development of fully-evaluated action plans that promote the mental health and resilience of young people during times of transition is needed. These plans should take into account the lifestyles and networks of young people and provide choice by offering a broad range of interventions.
5. There is a need for the implementation of action plans that target young people and ensure young people participation in their development. These plans should be fully evaluated and measure positive changes with regard to young people’s knowledge of mental health problems; their attitudes to mental health problems; and their behaviour towards those with mental health problems.
6. All organisations need to address the challenges inherent in ensuring meaningful young people participation. This will include reviewing the ethos, culture and practices of organisation/s to ensure that participation policies are in place and fully implemented. Young people participation should be fully evaluated and include the measurement of outcomes (beyond solely those of the experience of participation), such as whether/how services have improved.
Literature Review 13
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Right Here is an ambitious five-year project from the Paul Hamlyn Foundation and the Mental Health Foundation. It aims to revolutionise the prevention of mental health problems among people aged 16-25. It will also tackle the stigma attached to mental illness that often stops young people asking for help.
Right Here will invest in partnerships between public and voluntary sector organisations across the UK. These will pilot new ways of working to protect young people’s mental health.
For more information about the project visit www.right-here.org.uk or email email@example.com
© Mental Health Foundation & Paul Hamlyn Foundation 2008 ISBN 978-906162-20-7
Right Here is a collaboration between Paul Hamlyn Foundation, a company limited by guarantee registered in England and Wales (no. 5042279) and a registered charity (no. 1102927) whose registered office is at 18 Queen Anne’s Gate, London SW1H 9AA, and the Mental Health Foundation, a company limited by guarantee registered in England and Wales (no. 2350846) and a registered charity (no. 801130) whose registered office is at Sea Containers House, 20 Upper Ground, London SE1 9QB.