Manchester Health and Wellbeing Service Public Mental Health Team Evaluation of Connect 5 training between April 2013 and March 2015 1. Introduction 1.1 Connect 5 is designed to increase the confidence and skills of front line staff so that they can be most effective in having conversations with the people they work with about mental health and wellbeing, and so help people to manage mental health problems and increase their resilience and mental wellbeing through positive changes. 1.2 • • • • • •

This report: explains the background and evidence base for Connect 5 [section 2.] indicates the quality assurance process for the trainers who provide the training [section 3.] documents the way that evaluation is conducted [section 4.] provides statistics about courses provided [section 5.] details the main findings of the evaluation [section 6.] summarises the views and experiences of participants [section 6.]

1.3 Evaluation and consequent recommendations from all stages of Connect 5 delivery are considered, including: • • • •

Pre-training discussion Evaluation at the end of each session Recap at the start of session 3 Focus groups

1.4 The views and experiences of participants attending Connect 5 training delivered by Manchester Public Mental Health team between April 2013 and December 2014 are summarised within the evaluation findings. The purpose of the evaluation is to: • • • •

Determine the effectiveness of the training Record the views of those who attended Identify potential improvements to the course Inform changes to the evaluation of the training

1.5 The main findings and recommendations arising from the different methods of evaluation are discussed [section 7] and listed and the team is in the process of implementing these. [section 8]

2. Background and Evidence Base for Connect 5 2.1 The original course, Interventions in Mental Health for Everyday Practice, was designed in 2007-2008 by Jane Briddon and Clare Baguley at EDTA, a mental health training agency within the University of Manchester, School of Nursing, Midwifery and Social Work, based on the ‘SCAN’© (Screening, Care, Advice, Next steps) model for training developed by leading national experts in Primary Care. EDTA was using this model to train mental health staff and IAPT (Increasing Access to Psychological Therapy) workers. The package had been developed from an earlier training package written by Dr Karina Lovell and Professor David Richards at the University. The basis of the model is the cognitive behavioural approach to mental health with added emphasis on environmental factors, designed as a brief structured intervention rooted in guided self help.1 2.2 The techniques covered in Connect 5 flow from the knowledge base and philosophy of cognitive behavioural therapy. The intervention is collaborative, so the client is encouraged to share responsibility for and to be an active co-participant in the work. The frontline worker is taught to help the people they work with need to understand themselves through a process of ‘guided discovery’, so that they find out about themselves for themselves and make their own decisions, rather than expecting the frontline worker to ‘fix’ things for them. The intervention techniques should help people to learn skills which enable them to cope with future adversity in a more effective way.2 2,3 It is also intended that the training will address the needs of people who do not reach the threshold for clinical / medical mental health services – since the health care system will not be able to be expanded to meet those wider needs. This involves population-wide dissemination of informal self-help strategies that have evidence for effectiveness, and may avert the development of many clinical cases.3 2.4 The course includes brief sections on identifying and responding to risk, by helping participants to practise how to gather information from someone they are working with, and by providing brief guidance on how to respond. 4 2.5 Connect 5 deconstructs and expands the concept of mental health to include positive mental wellbeing. This in turn expands the remit of all frontline staff – whether in the public, private or voluntary sectors – to contribute to promoting mental health and wellbeing.5 This is particularly pertinent for local authorities, which now have responsibility for public health commissioning.6 2.6 Connect 5 was developed from the original IMHEP course by Manchester Health and Wellbeing Service (in Manchester Mental Health and Social Care Trust) in partnership with Public Health in Bolton and Stockport. The programme in its current format, as amended and developed by the trainers involved as a result of their own expertise and feedback from participants, has been delivered since January 2013.

3. Quality Assurance Process for Trainers 3.1 The trainers all have teaching / training qualifications, and have all been through a ‘training the trainers’ programme for Connect 5 itself. The course is managed by public mental health specialists. 2

3.2 The trainers provide peer review / feedback to each other as necessary after each training session. Quarterly training development practice sessions are held which enable the trainers to refresh their knowledge and understanding of the principles and content of the course, to practise particular aspects or sections of the course, and to consider any new developments which should be incorporated.

4. Evaluation Methodology 4.1 Before Connect 5 is provided for an organisation, the relevant manager is interviewed in order to fill in a pre-course questionnaire. This is used to check that the expectations of the organisation and the prospective participants match what Connect 5 covers. It also allows identification of any specific needs for the organisation and/or for individual participants. 4.2 At the end of each of the three sessions which make up Connect 5, participants complete an evaluation form. The format of the evaluation forms mainly asks participants to assess whether they have improved their skills and knowledge in specific aspects of the session, but also allows for free text comments. 4.3 At the start of Sessions 2 and 3, participants complete group exercises to show how much they have remembered of the content and philosophy of the previous sessions. This enables the trainers to gauge how well participants are prepared for the session to come, and whether they need to go over any gaps. The information from these recap sections has also been used to make small changes to the previous sessions to try to ensure that anything which was not clear is amended. 4.4 Further evaluation is carried out with organisations for which the whole of Connect 5 has been provided. About two to four months after the final session, organisations are asked to convene a ‘Focus Group’ of their participants to go through a semi-structured questionnaire. The main purposes of this are to check how much of the course the participants remember, but more importantly, how much of it they are putting into practice and what impact it has had on the people they work with. This also includes whether they have used the self help guides, and what impact these have had.

5. Course numbers and participants 5.1 From April 2013 to March 2015, there were 127 sessions of Connect 5: April 2013 to March 2014: Session 1 – 41, Session 2 – 16, Session 3 - 10 April 2014 to March 2015: Session 1 – 23, Session 2 – 18, Session 3 – 18 plus 1 special session for Health Trainers Of the 127 sessions, 75 were for a total of 32 different organisations / services and 52 were Open courses. Ten organisations / services went through all three sessions of Connect 5.

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5.2 In the two years, 312 people attended all three sessions, plus 11 Health Trainers did a special Session 3 (as they were already using the 5 Areas Model or similar model). 135 people did just Sessions 1 and 2, and 460 did just Session 1. 5.3 In the first year, April 2013-March 2014, a smaller proportion of participants completed all three sessions; a much higher proportion just did Session 1: • Only Session 1: 354 • Sessions 1 and 2: 116 • All three Sessions: 98 From April 2014 to March 2015, a larger proportion of participants worked through all three sessions: • Only Session 1: 106 • Sessions 1 and 2: 19 • All three Sessions: 214 5.4 The Public Mental Health Team carried out focus groups with eight different organisations / services or teams which completed all three sessions of Connect 5, and there was one focus group for people who had attended Open courses for all three sessions. The eight organisations / services which took part in focus groups and provided follow-up evaluation were: Access Summit Community Alcohol Team Cornerstone Day Centre Manchester City Council Family Intervention Programme, North and South teams Riverside ECHG, including Street Buddies, workers and volunteers in hostels and Prison Visitor Centre • Sign Health • Integrated Care Team, South Manchester • • • • •

5.5 There were two other teams which have been all through the three sessions, but with whom we were not able to arrange focus groups: • South Manchester Healthy Living Network volunteers • Manchester City Council Housing Connect Support Team 5.6 As a focus group could not be arranged in an appropriate timescale, the South Manchester Healthy Living Network provided some feedback. The aim of including the Healthy Living Network volunteers in Connect 5 was so that the Healthy Living Network could extend the ‘reach’ of the wellbeing conversations and the use of the self-help guides into the local community, through the weekly Health Information Points. The Healthy Living Network staff monitor the use of the Health Information Points, so knew that they could monitor the impact of the Connect 5 training on the volunteers’ work. The other direct outcome of attending Connect 5 was that a group of the volunteers who had done the Connect 5 training were trained to deliver Boost. Boost is a course provided direct to members of the public who want to improve their wellbeing and develop life skills to do with mood, assertiveness, self 4

esteem, self confidence, dealing with problems. Attendance at Connect 5 is not a prerequisite for delivering Boost but the two courses use the same approach and models, and the Healthy Living Network staff felt it was a good pathway for the volunteers, and it has proved to be very successful.

6. Evaluation Methods and Findings 6.1

The main findings from the different evaluation methods were: • • • • •

Average 83.2% improvement in knowledge and awareness across the three sessions The most popular tools are the 5 areas model and 5 ways to wellbeing Raised awareness of services and signposting for clients Attendance at all three sessions increases the use of self help guides Participants and organisations would like regular updates about mental health and wellbeing to keep it at the forefront of their working role within Manchester.

6.2 Pre-course discussion 6.2.1 Before the delivery of Connect 5 training the Public Mental Health team visits organisations to find out: • what they expect from the Connect 5 training • team members’ knowledge of mental health and wellbeing prior to the training • the gaps organisations face in supporting peoples’ mental health • support within organisations to integrate learning from the training. • any specific needs participants may have that we would need to take into consideration in delivering the training 6.2.2 The main reasons for wanting Connect 5 training were: • increased working with people who experience mental health condition • to ensure that staff have a standard level of understanding about mental health and wellbeing, and how they impact on people’s daily living • to increase participants’ confidence in having conversations about mental health • to ensure that people were being referred and signposted appropriately to other services • to find appropriate resources to use with clients. • an opportunity to re-focus their learning and refresh their knowledge for those participants who already had a good knowledge of mental health 6.2.3 The range of participants’ experience in the area of mental health ranged from very little to higher education qualifications or above. Many of the managers felt that, regardless of someone’s professional qualification, all their team members would benefit from the Connect 5 training as it would work as a way of refreshing their current knowledge, increase their awareness of mental wellbeing and put everyone at the same level in regard to what support they can offer to clients.

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6.2.4 Organisations / services and teams already do a lot within Manchester to support their clients’ mental health. Referrals are made where appropriate, and some organisations carry out assessment which includes questions around someone’s mental health diagnosis. 6.2.5 The main gaps identified within support for peoples’ mental health were to do with referral for clients into other services and lack of awareness about services people could access and how. There was also a gap in people’s knowledge and awareness of mental health in general and a feeling that this impacted on the care a client would get depending on which staff member they went to, as everyone worked in different ways. 6.2.6 Very few organisations used self help guides prior to the delivery of Connect 5 training. The one place that said they had some available did not actively give them out to clients. 6.2.7 All organisations involved in this report had good management support for the learning from Connect 5 to be integrated into participants’ working role. They also have systems in place to record, albeit anecdotally, the impact of the learning through supervision, increase in staff confidence in supporting clients’ mental health, and increase in families accessing different services. 6.3 End of Session Evaluations and Recap 6.3.1 After each session participants were asked to complete an evaluation form to collect data on people’s improvement of knowledge and confidence in a variety of aspects of the training. 6.3.2 Generally, the tools and models and emphasis on conversation skills were felt to be useful, and the sessions were structured and well organised. Participants who tried tools and ideas between sessions found them easy to use, helpful for clients, and helped them to feel more confident in discussing mental health issues. In particular they learned to take a step back and use communication skills to listen to clients, rather than immediately trying to find solutions to problems. The main concerns were to do with lack of self confidence in using new tools and doing or saying something wrong. There was high overall self-rated improvement at the end of each session: Session 1 – 82%; Session 2 – 84%; Session 3 – 87%. Participants went away from the final session with action plans of how they would use their learning within their working role. 6.3.3 Session 1 6.3.3.1 There was 82% improvement overall within the evaluation for Session 1. The main things that participants said were the most useful from the half day session were: • • • •

5 areas model 5 ways to wellbeing Conversation skills More information about services in Manchester

6.3.3.2 Most people found Session 1 to be a good start for improving their awareness of mental health and mental wellbeing. They found the materials easy to understand and very 6

engaging. There was a feeling that the structure of the session was well organised and participants became excited about attending future sessions. 6.3.4 Session 2 6.3.4.1 Overall there was 84% improvement within all areas of the evaluation for Session 2. The main things that participants said were useful include: • BATHE [this is a method to help people to get into wellbeing conversations, using the headings: what do you do - Behaviour, how does this Affect you, what Troubles you most, how do you Handle it now, and showing Empathy] • 5 areas model • Exploring intensity • Using role models to practise learning 6.3.4.2 Participants found the information shared within this session was very relevant to their working role. They found it to be engaging and well organised. Some felt that there needed to be more instruction before the role play/practice in 3s as some people found it difficult to know exactly what they were supposed to do during these sessions. A request for videos of good practice to be included in the training session was made by a few participants to help their understanding of the different tools and to see how they should be applied within a conversation. 6.3.5 Session 3 6.3.5.1 During the recap at the start of Session 3 some time was spent looking at the things participants had tried since Session 1 and 2. 6.3.5.2 Since Session 2 the main thing participants said they had tried was the 5 areas model and showing clients the links between all the areas (the vicious cycle). Participants had also found the 5 ways to wellbeing was a useful tool to use with both participants and for themselves as way to encourage trying new things. Participants had tried BATHE and found it to be an effective tool to get people to open up and direct the conversation in a short space of time. 6.3.5.3 The main things participants were pleased with was more awareness of the communication skills they used, focusing a lot on open questions, active listening and picking up on cues rather than focusing on paperwork. A lot of participants felt they had increased confidence to be more open about mental health and discuss a client’s situation. 6.3.5.4 This particularly included asking about suicidal thoughts. There was a sense that this was a less overwhelming topic to discuss than it had been prior to training. Some participants had specifically explored a client’s suicidal thoughts and felt more confident in asking questions around this without feeling so fearful about the possible response. 6.3.5.5 Participants had learnt a lot about all the different services within the Manchester area and were pleased with how many different places they could now refer clients to. The only concern around this was around access to some services as some participants felt that sometimes there were barriers in place preventing clients getting the help they needed. 7

Furthermore, financial cuts for public and voluntary sector organisations meant some services were becoming more restricted or not available. 6.3.5.6 Participants had also learnt to take a step back from situations and not go straight into finding solutions for clients. Along with this there was also a new understanding around taking things just one step at a time and not trying to do everything all in one go. 6.3.5.7 The main concerns raised were around a lack of self confidence in using new tools and doing things ‘wrong’. Some participants were fearful of what they might do if they didn’t use models in a correct manner and the damage that might cause for clients. As they were non-medical members of staff there was a sense of not wanting to overstep their boundaries and a need for clearer guidelines of where their ‘helping’ role finishes and where a referral should be made. 6.3.5.8 Some participants felt that they were still focusing on their own needs in sessions with clients and struggling to change their way of working. Because of a demand for targets and paperwork, it felt overwhelming for some to be able to fit anything else into a session with clients. Others also struggled with the time barriers of their job and felt they didn’t have the space to be able to do things such as exploring intensity with clients as their sessions were so brief and structured. 6.3.6 Session 3 – end of session evaluation 6.3.6.1 At the end of Session 3, the evaluation forms show 87% improvement overall in all areas of the evaluation. The main things that participants said were useful included: • Tools to use within different areas of the 5 areas model • Exploring intensity and stepping up flow chart • Use of characters throughout the training 6.3.6.2 Some participants shared how the training had made them more aware of the normality of suicidal thoughts, and being able to pass this information on to clients had been a release for some as it took away some of the fear of what they had been thinking. 6.3.6.3 Overall participants enjoyed the final session and went away with plans of how they would use their learning within their working role. Participants got a lot out of the whole overall learning experience and felt they had more confidence and understanding around supporting clients to improve their mental wellbeing. 6.4 Post-course Focus Groups 6.4.1 Focus groups are held in organisations which have completed the whole of Connect 5 about 2 to 4 months after the end of Session 3. At the start, some people found it difficult to remember specific points from the training. With a bit of probing, they did remember more, and it was clear that they had been using a range of skills and tools they had learned on the course. (See Appendix 1 for anecdotal case studies shared within focus groups; see Appendix 2 for examples of Healthy Living Network Wellbeing Conversations as participants were unable to attend a focus group.) 8

6.4.2 • • • • • •

The main things that people remember from the training were: 5 ways to wellbeing 5 areas model BATHE Characters Information about resources and services Axis of mental health and wellbeing

6.4.3 The 5 ways to wellbeing had encouraged people to make small changes and try something new. They have given the 5 ways information sheet to people as a reminder of what they can do for themselves to improve their wellbeing. One service had used it as a basis for developing events, activities and sessions within their organisation to improve the wellbeing of their clients through things such as swimming, cookery and walks in the country. 6.4.4 The 5 areas model has also been used within services to unpick individuals’ situations and show them how all the different aspects impact on each other. Participants have then used this as a way to encourage individuals to pick their starting point for breaking their vicious cycle. Feedback on the 5 areas model was positive from all groups. Some participants had been using something similar for some time prior to the training but everyone who said they have used it felt it was a really easy, simple tool to use which had a very positive impact on individuals as they were able to look in detail at what was going on for them. It was something that participants said they went back to at later dates to show individuals how the small changes they had made had broken their vicious cycle and also to look at where else someone might like to make a change. 6.4.5 The self help guides had a very positive response from all those who had started using them. Participants felt that they had become invaluable to their role and were easy to read, effective tools to use collaboratively with clients or to leave with them to take away. Some organisations had set up a ‘borrowing service’ for the guides to allow clients to take them away for a short time before returning them on their next visit. They found that this ensured clients read through it in the time slot allocated and they would then follow it up in their next session together. There were some anecdotal stories shared in regards to people’s response and outcomes from the use of self help guides. These are in Appendix 1. 6.4.6 A significant number of participants felt more confident in talking about suicidal thoughts and self harm with the people they work with. They particularly said that the ‘exploring intensity’ questions and the procedural flowchart were very helpful in doing this. 6.4.7 Generally, participants felt more confident about talking to people about their mental health and wellbeing. One participant’s comments were typical: she felt that her new learning had a very positive impact on the way that she worked as she now does a lot more to support someone’s mental wellbeing and has found that clients are listening to her and are making small changes in their lives to feel a little happier rather than always going to the GP and demanding a pill to fix things as they had in the past. 9

6.4.8 Those participants with an existing good knowledge of mental health had found it a good refresher, to confirm how effectively they were already working with people. They felt the training had helped to bring mental health back to the forefront of their thinking when working with clients. 6.4.9 Participants reported a greater knowledge of the services and resources available, and how to signpost clients to these. 6.4.10 The main concerns or criticisms were about the length and intensity of the training, and the difficulties of adding a focus on mental health and wellbeing to existing heavy workloads and work with people with complex needs. Some people who have very pressured working roles where they support clients who have complex needs quite intensively, felt that attending full days of training was too much of a burden. It took them away from work for too long and fitting the training in was quite difficult. For others a whole day’s training felt too much for them to be able to take in and use all of the information given to them. Some of the teams thought it would have been more useful to have the training spread across more half days so they would still be able to meet the daily needs of their clients and also digest some of their learning before coming back for the next session. 6.4.11 A difficulty in taking Connect 5 on board was around the amount of work expected from participants within their organisation. Some felt that there was already a lot asked of them to complete during their time with clients and that it wasn’t always possible to focus their time on someone’s mental health as there were so many other things that would need to take priority. They may have planned to use their new learning during a meeting with a client but would have to put it on hold if other things came up. When managers and supervisors were themselves involved in the training, they were more able to help to embed the tools and skills into working practice for staff and volunteers, and to deal with some of these concerns. 6.4.12 Participants had also struggled with their learning when there was a long gap between attendance at sessions. This was mainly within the open courses where people were unable to book onto courses close to each other due to demand. They had forgotten some of the learning and didn’t always understand the connections made within the sessions straight away. 6.4.13 For some organisations there was a need for more information around young people and mental health. Participants felt that the course had been effective for their support of adults but were unsure how the tools could be altered for use with teenage clients. There was also a sense that, for some organisations, the characters used did not fully reflect the individuals they worked with. Because of this some participants found it difficult to understand how the tools could be used with clients who had complex needs or chaotic lives. 6.4.14 Overall there was an increase in people’s confidence in regards to talking to people about their mental health and wellbeing. People enjoyed being part of the training and felt that having regular refresher sessions would be useful to keep them focused on mental health and wellbeing. They felt refresher sessions would also remind them of the tools and interventions taught through the course and how to use them with clients. Participants felt 10

that this could be done through either six-monthly meetings and/or regular newsletter style emails.

7. Discussion 7.1 The general level of satisfaction with Connect 5 was high, especially in terms of awareness of mental health and wellbeing issues. Use of the specific tools and models was patchier. In particular, the interventions suggested in Session 3 for each of the 5 areas had not been tried widely. The more concrete tools, such as Activity Scheduling (for the behaviour area) had been used by some participants. A lot of participants did not recognise the importance of ‘just talking and listening’ and helping people to clarify their thoughts or to be more self compassionate, since there is not a specific intervention tool for these. So they often did not report on such issues until responding to more probing questions. Or they felt that these were things they did anyway and Connect 5 had not changed their practice. 7.2 A lot of what managers stated they wanted within the pre-training evaluation has been mirrored in the findings within the focus groups. Managers wanted to have a basic standard level of knowledge around mental health and wellbeing within their organisations and this was achieved through the Connect 5 training, whether as a refresher for those with professional qualifications, or a new area of knowledge and understanding for those new to mental health. Gaps that were identified by managers around accessing services have been filled and participants are now signposting a lot more than before training. 7.3 Connect 5 seems to work best when managers / supervisors understand fully the purpose and tools of the training, and help their staff and volunteers to implement these and embed them into their practice. Because of this it is important to keep managers engaged in the training process throughout the whole of Connect 5. 7.4 A significant number of participants reported that they felt more confident in talking about suicidal thoughts and self harm with the people they work with. They have used the tools and skills they learnt to explore intensity with clients and have acted in a manner that kept themselves and their clients safe. Some participants have also signposted to services such as The Sanctuary to ensure that clients are safe at all times. 7.5 All participants involved in the focus groups talked about how they used self help guides within their organisations since the training, whether this was a brief conversation or spending time working through the guide in a one-to-one setting. This anecdotal increased use of the guides is backed up through an increase in collections from Victoria Mill (further details of this are available on request). Although many of the participants didn’t clearly state they were using the interventions within focus group sessions, our database shows that organisations are taking and using the guides that connect to the tools we teach. From this it is safe to assume that participants are using their learning from Connect 5 more than they realise. 7.6 The end of session evaluations and the focus groups indicate that all the pre-course expectations and requirements had been met for organisations. Overall, participants reported that there had been significant improvement in their understanding, awareness, confidence, skills and knowledge in relation to mental health and wellbeing, services and resources available, and how to support self management for the people they work with. 11

8. Recommendations 8.1 Timing: We could offer different formats to fit in better with organisations’ ways of working, such as 4 x half days for Sessions 2 and 3 or three short days to cover Sessions 2 and 3. We should discuss this with managers during contracting and pre-course work. 8.2 Recap and practice between sessions: Participants should be set specific tasks/tools to try between sessions and report on this at the next session, as well as or to replace the recap section. This would reinforce learning and help to embed tools into participants’ work. 8.3 Follow-up sessions: Several organisations asked for regular follow-ups to keep mental health at the forefront of their working role. This could be through email newsletters to all those who attend all three sessions, including information about resources, MHIM website, activities on Twitter / Facebook, new guidelines / good practice (e.g. suicide prevention). 8.4 Wellbeing sessions: Several teams asked for sessions on Self Help guides, to increase their knowledge and to see whether these would be useful for people they work with. 8.5 Future focus groups: We intend to concentrate more on how they have used the training and any impact on the people they work with, and to demonstrate how they are using the tools and models, rather than asking for detail of what they remember about the course. 8.6 Follow up with managers: Sometimes participants’ aims do not entirely match the manager’s hopes of outcomes from the training. We need to check with managers whether their objectives for the team have been met. This will help to encourage managers to support staff and volunteers to embed Connect 5 principles and tools in working practice. 8.7 Adaptations and Flexibility: We are working on adapting Connect 5 to make it more suitable for people working with young people, children and with clients with more complex needs or chaotic lifestyles. We could offer participants more flexibility to use information about people they work with as well as or instead of the characters – especially in Session 3, when discussing interventions. 8.8 Signposting: One of the main things participants say has improved is the signposting they do into other services and community based activities. So it is vital that the Public Mental Health team keep the ‘Help!’ leaflet up to date and accessible on the MHIM website. 8.9 5 Ways to wellbeing: Because some organisations have been focusing on using this model with clients, with positive anecdotal outcomes, we should refer to this model in all sessions to emphasise the importance and positive impact it can have on individuals’ lives. 8.10 Facilitation: As some participants struggled with instructions for some aspects of the training all trainers should be very clear about what they are asking participants to do and ensure they set up practice sessions as clearly as possible. 8.11 Reinforcement of ‘just talking’ benefits: A number of the participants were unclear as to the importance and the impact that ‘just talking’ to clients can have on their mental health and wellbeing. This is something we should emphasise in all of the three sessions. 12

Appendix 1 Anecdotal case studies shared by participants within focus groups Case study 1 I have been working with a participant on a weekly basis for over a year now. I have been using some of the learning from Connect 5, especially the 5 areas model and have revisited it a number of times during our time together. We have both been able to see small changes within his situation over this time and I am pleased to report that we are finally coming to the end of our sessions as we have been able to unpick his most troubling problems and find simple solutions to them together. Case study 2 I have been working with a mother for a while and a few weeks ago she opened up in regards to having some very troubling thoughts at times about how much easier life would be for others if she wasn’t here. She stated that she would never take action because of her children and she didn’t really want to talk much else about it. I made sure she was safe and left the self help guide ‘I feel so bad I can’t go on’ with her as she didn’t want to work through it together. I met up with her a few days later and she thanked me for the guide and told me how helpful she had found it in realising that she had a lot more going on for her and how important the people in her life were. Case study 3 I had seen a client on a number of occasions to support them to make a lifestyle change and they continued to have the same pattern of change. They would stick to their new way of living for a few weeks but then slip back into old habits. During one of my visits after Connect 5 I completed the 5 areas model with him and we unpicked a lot of things he was unaware of within his vicious cycle. We did some work together around making small changes and set a whole new plan of action out for him to follow. He has now followed his new lifestyle change for a few months and is really positive about the future. Case study 4 I have seen huge changes in some of the clients I work with and their level of dedication to their course since attending Connect 5 training. I have a lot more confidence now to question changes in clients when they show signs of being lower in mood. I have been more open to responding to cues and found that clients are a lot more focused on their work once we have spent some time talking about what has been going on for them. Case study 5 I have found the self help guides an invaluable tool when working with those who find it difficult to openly talk about their feelings and what is going on for them. We can use the guides together and then give them the space to fill in different sections alone if they don’t want to verbalise their response.

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Appendix 2 South Manchester Healthy Living Network: Examples from Wellbeing Conversation Monitoring Forms These indicate the use of the 5 Areas Model in helping people to understand how their thoughts, feelings, physical reactions and behaviour can be interlinked in a vicious cycle with their situation, and how simple techniques and resources can break the vicious cycle. The impact of long term health conditions and of problems with sleeping were particularly noticeable. The South Manchester Healthy Living Network staff said that one thing which stood out was how many men were taking up the opportunity to discuss their health and wellbeing. 1. Female, age 40s, white British Brief area of discussion: She suffers from depression and has taken antidepressants for a long period of time. She feels that antidepressants are keeping her condition stable. She admitted that she would like to return to work but she felt she had lost her confidence because she was off work for more than 6 months. She also admitted she has low motivation. Course of action undertaken: The vicious cycle of low self-esteem was explained. Challenging unhelpful thinking techniques was explained. How to build yourself up was explained. How to treat yourself well was explained. How to cope with setbacks was explained. Activity scheduling techniques were explained. 2. Male, age 60s, white British Brief area of discussion: He thinks that people are treating him badly. He feels hurt and upset about it. He is feeling down because of it. He thinks that he is not confident to stand up for his own opinion. Course of action undertaken: Explained how way of thinking affects emotions and behaviour. How important it is to perceive our self in correct way. How to build confidence and selfesteem. 3. Female, age 30s, Asian Brief area of discussion: She has extensive worries about the health of her children. Those worries are affecting her day-to-day life. She is feeling tired and stressed. She is expecting bad things will happen any minute. Course of action undertaken: Vicious cycle of anxiety was explained. The effect of negative thoughts was explained. Recommended to use thought diary to understand that her thoughts can affect emotions and behaviour and create physical symptoms. Recommended the worry tree and distraction techniques. 4. Male, 70s, Irish Brief area of discussion: He feels low motivation to do work in his house. He links this to his arthritis – he often experiences pain in his joints. He described himself as a DIY man in the past. He feels very frustrated that he is not able to do DIY work and garden work any more and he had to pay for somebody else to do these jobs. 14

Course of action undertaken: Vicious cycle was explained. How to break the cycle was explained. Importance of diary keeping was explained. Important of routine and activity scheduling to keep plan working was explained. 5. Male, 60s, Asian Brief area of discussion: He has long term health condition, diabetes. He was complaining of anxiety and poor sleep. He admitted that he has lots of worries about his health condition. He worries that the disease will get worse. Course of action undertaken: Explained about health anxiety and the vicious cycle of anxiety. The effect of negative thoughts was explained. Thought diary technique was explained. Thought challenging technique was explained. The worry tree technique was explained. Distractions technique was explained. Bedroom routine to help sleep was explained.

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Notes and References 1 This promotes the philosophy of helping people to understand and manage their mental health problems, including those environmental factors that influence mental health or are a consequence of poor mental health. The thinking is akin to the principles of ‘Recovery’. Promoting self management is a cornerstone of current policy in health and social care, and is fundamental to the cognitive behavioural approach. Connect 5 is thus consistent with the approach of first line specialist services. Independence, choice and risk: a guide to best practice in supported decision making (2007) www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/ dh_074775.pdf CG136 Service user experience in adult mental health: NICE guideline (2011) www.nice.org.uk/nicemedia/live/13629/57534/57534.pdf Kings fund transforming our health care system (2011) www.selfmanagement.co.uk/sites/default/files/files/Ten_priorities_for_commissioners1%20(2) .pdf 2 IAPT: CBT competences framework for depression and anxiety disorder www.ucl.ac.uk/clinical-psychology/CORE/CBT_Competences/Generic_Competences/ Generic_Competences.pdf 3 Population promotion of informal self-help strategies for early intervention against depression and anxiety Anthony F. Jorm and Kathleen M. Griffiths, Psychological Medicine, 2006, 36, 3–6. 2005 Cambridge University Press 4 Independence, Choice and Risk: a guide to best practice in supported decision making. Dept of Health 2007 This best practice guide is for the use of everyone in supporting adults using health and social care within any setting. This guide is intended to help those involved in helping individuals to retain greater control of their lives. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH _074773 5 Mental Capital and Wellbeing; Foresight Report https://www.gov.uk/government/collections/mental-capital-and-wellbeing This report from 2008 used scientific evidence to advise government on how to achieve the best possible mental development and mental wellbeing for everyone in the UK. No Health without Mental Health: a cross-government outcomes strategy https://www.gov.uk/government/publications/no-health-without-mental-health-a-crossgovernment-outcomes-strategy The government’s strategy from 2011 to improve the mental health and wellbeing of the whole population; to improve outcomes for people with mental health problems with high quality services equally accessible to all. 16

6 The role of local government in promoting wellbeing (2010) www.idea.gov.uk/idk/core/page.do?pageId=23691278 “Wellbeing is sometimes seen by local government as the remit of those concerned with health provision. But health services are primarily designed to treat illnesses, not to address the broader aspects of people’s lives that create the conditions of wellbeing. Intervening only at the point when someone has become unwell is unlikely to be the most effective way to achieve significant and enduring change. To fulfil local government’s forthcoming responsibility for public health improvement, wellbeing will have to become central to local government’s agenda and no longer solely a matter to be dealt with by those with ‘health’ in their job titles”

For further information about Connect 5 in Manchester, contact: Caroline Bedale, Senior Health & Wellbeing Advisor Health & Wellbeing Service, Victoria Mill, Lower Vickers Street, Manchester M40 7LJ Tel: 0161 882 2579; email: [email protected] June 2015 17