Steps to prevent poor mental health Taz Edwards-White, The Metro Centre Tim Franks, PACE Laurie Oliva, Stonewall C

1. Steps to prevent poor mental health TazEdwards-White, The Metro Centre Tim Franks, PACE Laurie Oliva, Stonewall Chair - James Taylor, Stonewall

2. Promoting mental health for LGB young people Tim Franks – CEO PACE

3. Really, Really, Gay

4. 5 steps to happy LGB YOUNG PEOPLE • Get the issue • Address the environment • Someone to talk to • Being heard • People like me

5. What’s going on? • Disproportion • 2008 Prof Michael King - National Institute for Mental Health published a systematic review: “Mental disorders, suicide and deliberate self harm in lesbian, gay and bisexual people.” • Rates of attempted suicide more than double for LGB people (NB gay men over 4 times more likely) • At least 1.5 times more likely to suffer from depression over 12 months or a lifetime • At least 1.5 times more likely to become alcohol or drug dependent (NB lesbian women 4 times more likely to become alcohol dependent)

6. In other words: “LGB people are at significantly higher risk of mental disorder, suicidal ideation, substance misuse, and DSH than heterosexual people. An awareness of the mental health needs of LGB people should become a standard part of training for health and social work professionals.”

7. More about the issue • Chakraborty, A. et al. Mental health of the non-heterosexual population of England. British Journal of Psychiatry, Vol. 198, February 2011, pp. 143-48. • 4.1% of non-heterosexual people reported having had a depressive episode within the last week compared to only 2.1% of heterosexual people • 10.4% of non-heterosexual people reported alcohol dependence compared to 5.4% of heterosexual people • 8.6% of non-heterosexual people reported self-harming compared to 4.6% of heterosexual people.

8. No health without mental health “People who are lesbian, gay and bisexual all have a higher risk of mental health problems and of self-harm. They also suffer more attacks and violence. Experiences of mental health services are reportedly poor, and monitoring of sexual orientation is patchy, making it less easy to develop tailored service responses.”

9. Why disproportion? Discrimination is a prime suspect! “It is likely that the social hostility, stigma and discrimination that most LGB people experience is likely to be at least part of the reason for the higher rates of psychological morbidity observed. Prejudice against homosexuality is unlike other intolerance in that it can reach into families; rejection by parents of their own children because of their sexual orientation is likely to have a severe emotional impact.”

10. Minority Stress Meyer, I. Minority Stress and Mental Health in Gay Men, Journal of Health and Social behaviour 1995, Vol. 36, 38-56 • Internalised negativity • Experience of discrimination and violence • The expectation of rejection and discrimination • NB – the bisexual experience – The Bisexual Report

11. Step 2 – address the environment • Aware staff • Challenge bullying and discrimination • Come out as LGB friendly • Support for families

12. Recovery from homophobia Healing from cultural victimization: Recovery from shame due to heterosexism. Neisen, Joseph H. Journal of Gay & Lesbian Psychotherapy, Vol 2(1), 1993, 49-63 • Break silence • Establish perpetrator responsibility • Reclaim personal power

13. Step 3 someone to tell • Every young person should know how to access safe, confidential information and support on LGB issues from an LGB or LGB friendly adult with the minimum of effort. • Safe • Confidential • LGB Friendly • Minimum effort

14. Step 4 being heard “When you assume that I’m straight you make it clear to me that your services aren’t relevant to me or my life, which pushes me closer to letting go of life. I am already working as hard as I can to stay alive moment by moment. I don’t have the energy to constantly come out to you, and then have to deal with your homophobia or ignorance or confusion.”

15. “even though I’d told them why I’d taken the OD and slit my wrist (‘cos of a breakup from my girlfriend), I don’t remember her mentioning this – I felt invisible.”

16. “[therapist] referred to my partner throughout the session as my ‘friend’, despite me calling her my partner. Towards the end of the session, she burst out: Are you telling me that the friend who brought you here is your sexual partner?... I didn’t go back”

17. “Statutory mental health services... I was constantly asked if I had a boyfriend even though I had stated I was a lesbian. When I mentioned that I had to keep explaining that I was a lesbian to my CPN she laughed.”

18. “My GP was extremely useful because my main problem was my rejection from my mother, and because she was a single parent, she was all I had. My GP knew us both and made me realise that some people are gay and it’s no ones fault.”

19. Being heard • Respond well – • affirm • offer help • easy with the words (find a word for partner and stick to it) • arm the challenge to internal negativity • Monitor • Refer

20. People like me • Belongingness needs • If isolation is part of the problem -community is part of the answer • Support structure • Adolescent peer interest • Learning the ropes (filling the gaps)

21. ‘Thank you for noticing me... when no-one else did’ Steps to prevent poor mental health amongst LGBT young people. Presenter: Taz Edwards-White Mental health and well-being co-ordinator The Metro centre.

22. 6 Steps to be covered: Step 1. Find out about... current overview, research, strategies and resources. And use them! Step 2. Discover... defining indicators of mental health issues in LGBT young people. Step 3. Understand... the biology bit. Step 4. Build... resilience and protective factors. Step 5. Know... our role as grown ups. Step 6. Take notice and...ASK. ?

23. Step 1. Current overview, research, strategies and resources. • No health without mental health 2011(Department of health)- Improving Access to Psychological Therapies to young people. • The Child and Maternal Health Observatory (ChiMat) is a national public health observatory established to provide wide-ranging, authoritative data, evidence and practice related to children's, young people's and maternal health. • CAMHS(Child & Adolescent mental health services) • TAMHS (Targeted mental health in schools) • NICEGuidelines MH(National institute of clinical excellence) • Healthy lives healthy people 2010- establishing directors for public health and local health well-being boards. • White paper and healthy child programme, /Green paper. • The equality act 2010-requires public sector to have ‘due regard’ to meet the needs of those who identify as LGBT.

24. Current statutory & Policy framework legislation & government strategies ...aim to deliver better mental health outcomes for people of all ages, this has led to many third sector organisations and services such as CAMHS to respond with ways to promote well-being in young people, this is shaping the future of children's mental health and emotional well-being services. • There are many, many recommendations, guidelines, resources and toolkits that cover everything from building resilience, tacking stigma for LGBT mental health to challenging homophobic bullying, promoting exercise, healthy eating and peer support.

25. Step 2. Defining indicators of 2 most common mental health issues in LGBT young people. Depression Excessive: • Irritability,/snappy • Poor concentration • Hopelessness and helplessness • Voice tone flat • Feeling sad, low mood • Change of appetite • Social withdrawal • Sleep difficulties, early waking. • Lack of interest or no pleasure in doing anything • Low self-esteem • Low motivation Anxiety Excessive: • Worry • Avoidance • Restlessness/difficulty in drifting off to sleep • Psychosomatic pains • Shyness • Social withdrawal • Impulsiveness/risk taking • Perfectionism • Fast and sustained physical arousal, heart pounding • Low self-esteem

26. You might say I have just described any ‘moody teenager’... • And you’d have a point! It can be difficult to distinguish the difference between what are normal changes in behaviour in a LGBT young person and the disturbances that may represent the early signs of a mental illness. This presents us with an interesting question, and brings us to step 3 the biology bit!

27. Step 3. The biology bit: the teen brain... • Evidence suggests that the teen brain is different in terms of its circuitry involved in emotional responses. • The responses of teenagers to ‘emotionally loaded’ images and situations are heightened relative to younger children and adults. • Enormous hormonal changes take place during adolescence, reproductive hormones shape not only sex related growth and behaviour but overall social behaviour. • Stress hormones can have complex effects on the brain and as a result behaviour. (National institute of mental health)

28. So how do we recognise if its hormones or a presenting symptom of mental ill health? So to answer our question: Whether its either/or to promote well being we need to acknowledge both. Brain based changes in teenagers contribute to changes in the regulation of sleep-which maybe the reason teens stay up late at night. This causes fatigue and sleep deprivation, and difficulty in maintaining attention. Sleep deprivation is a powerful contributor to irritability and depression and studies have found that sleep deprivation can increase impulsive behaviour. Understanding these changes taking place can present the opportunity to intervene early in mental illness. (NIMH)

29. Step 4. Build... resilience and protective factors. Resilience refers to a person’s ability to positively respond or adapt to and cope with stress. We all need resilience to maintain a basic level of well-being to manage stress but for an LGBT young person who is at increased risk of mental health issues its even more important. Ungar, Brown et al (2008) studied pathways to resilience and found that the youth capacity to cope under stress depends on different degrees of access to seven mental health enhancing experiences; • Access to material resources-posters, flyers , positive LGBT/MH role models • Access to supportive relationships-supportive family/significant adults • Development of a desirable personal identity-high self esteem • Experiences of power and control-feels in control has choice • Adherence to cultural traditions-faith and sense of meaning • Experiences of social justice-fairness • Experiences of a sense of cohesion with others-positive peer support/belonging.

30. Protective factors Protective factors refer to factors that prevent or reduce vulnerability and build resilience. Bender et al (2007) emphasise that ‘as choice is essential to motivate change, youth who believe they have even modest personal control over their destinies will persist in mastering tasks and become more committed to making positive life changes’ Young LGBT people struggling with mental distress often feel they don’t have a voice and by keeping their sexuality and mental health issues concealed due to real or perceived stigma and trans, bi, homophobia they feel invisible...

31. Step 5. Know... our role as grown ups. We know the current overall framework in which we are working in...What I would like to do now is bring it down to experience. All the policy, evidence, research and recommendations mean nothing unless it translates into meaningful experiences. Lets reduce it all down from the grandiose ideas to something simple. Between you and the young person.

32. Our role? We are involved in a dynamic system that we unconsciously play out with the young person . We are in danger of unconsciously playing out the ‘strict’ or uncaring parent role. If we fail to recognise how our moods and the way we conduct ourselves as ‘grown ups’ around the young person we may echo the relationship that they have at home. That for an LGBT young person may either be an aggressive or dismissive parent role. LGBT young people at higher risk of mental health issues will be particularly sensitive to your actions and reactions. If we are pre-occupied or in a bad mood the experience of asking the young person to wait until later... plays into rejection for that young person.

33. Step 6. Take notice and...ASK. ? We are only human...we all have good days and bad days and days where we feel ‘snappy’ or moody. We can not help that, but what we can do is TAKE NOTICE of ourselves. Be self aware and learn to spot how our behaviour may impact on the young person. If a young man ‘acts out’ and for example storms out of classroom/youth centre kicking over a chair on his way, you have a choice...you can either become that uncaring parent and shout, even dismissively tut. Or you can stop and think; what’s going on here and take notice. Try to understand that you don’t have to understand you just have to ASK the young person what your behaviour/actions meant to them and how it made them feel. TAKE NOTICE of what they are communicating. Listen.

34. ‘Thank you for noticing me, when no-one else did’. There has been cases where there has been abuse of young children , and parents nor social workers noticed. Adults can turn their attention away from what is happening to young people, this doesn’t mean ‘bad care staff’ or ‘bad parenting’ but it does meansthat people didn’t look for what was happening. They didn’t ask. They didn’t take notice. When they did ask it all came tumbling out. When a young person is asked ‘how are you feeling?’ even if they are unable to give an answer they will have a ‘check in’ with themselves momentarily and draw attention to their own thoughts, emotions and physiolological responses which in turn can raise self awareness and foster resilience. You can have a crowded room full of young people but one may feel invisible, the quieter kid that everyone leaves alone as they’re easy to manage...it’s our jobs as grown ups to stop and ask. As adults by taking notice of the warning signs, asking and listening, we can equip young LGBT people with emotional and social skills that give them resilience, prevent anxiety and prepare them in long term to deal with stressful life situations. I did ask the quiet young person in the crowded room and they said... ‘Thank you for noticing me, when no-one else did’.

35. 3 Quick LAST STEPS to prevent poor mental health amongst LGBT people... • TAKE NOTICENotice the warning signs of mental health problems.                  The signs usually aren’t one-time occurrences; they persist                 several weeks. Notice yourself and your actions and whether you are being helpful to the situation. • ASK  If you do see any of the warning signs, you can talk to the young person.                 Ask how he or she is doing, be respectful, compassionate and empathic as you can listen and respond. Ensure that you treat information as confidential. • SEEK SUPPORT    If you are worried about what you’ve seen or heard... Make sure the young person gets help:  Make sure the young person knows you are worried and that will need to break confidentiality. Talk to the young person first and tell them you are worried and would like to refer them to the appropriate service:                • A mental health professional or service at school or a service in the community                • A health professional (doctor, nurse) at school or in the community

36. The internet and prevention of poor mental health in lesbian, gay and bisexual young people Laurie Oliva Youth Engagement Officer Stonewall

37. LGB young people’s mental health Suicide attempts amongst young people Self harm amongst young people The bullying went on for the whole five years of secondary school. From when I started to when I finished. I tried to fight back. I was depressed, I cut, and I was on the verge of suicide. For one year, I came home everyday crying into my mum’s arms, saying I wanted to leave the school. Rabi, 15, sixth form college (Greater London)

38. The internet and LGB young people • Almost two thirds (63 per cent) of gay young people use the internet to meet other lesbian, gay or bisexual people. • Two in five (39 per cent) lesbian, gay and bisexual young people use social media, like Facebook. • More than one in three (35 per cent) use websites for young people, such as dedicated online youth forums. • One in ten (ten per cent) gay young people aged under 18 and one in three (33 per cent) 18 and 19-year-olds use dating websites for gay adults to meet other gay people and learn about gay life. • One in three (34 per cent) gay pupils say they can’t use school computers to access resources or information online about gay issues and a further 36 percent don’t know if they can. • “Meeting strangers from the internet is extremely appealing as it doesn’t share any of the threats that talking to people in your social circle has.” • Kevin, 17, secondary academy (South West)

39. Risks & Benefits • Cyberbullying- almost one in four lesbian, gay and bisexual pupils experience cyberbullying • Using adult sites • Suicide and self harm contagion • Access to inaccurate information • Reduced isolation • Increased self acceptance • Access information • Develop and test identities • Find out about offline support • Access peer support • Health information • Access to LGB culture & news • May come out online first • Get support when offline services not available Last summer, I was attacked on Facebook through a series of comments and wall posts calling me a ‘fag’. Harry, 16, single-sex private school (North West)

40. Reaching young people • Internet can be accessed anonymously and by any young person with internet access regardless of geographical location • It has the potential to reach young people who: • Are not out • Are geographically dispersed • Chose not to attend an LGBT youth group • Feel unsafe accessing mental health services as do not want to come out • Have had negative experiences related to sexual orientation when using health services • Who for other reasons do not want to use or are unable to use face to face community services

41. Peer Support “Hiya I could do with some help and tips on how 2 stop self-harming. Because I’m finding it really hard at the moment with all the exams and it doesn’t help that my mum is mad at me because I have kept that I’m bi away from her because she said it was a phase. I’m just so confused and self-harming is so tempting. Help please I need any tips. I’ve tried using my punch bag but I can’t seem to get it out of my head.” “I yet again have nobody to talk to.....not even in the sense of a distraction from my thoughts. Nobody....story of my life.”  “Can you get HIV from men 2 men?” “How important are condoms? I know they say if you leave it once, you can get an STD. Is this true?” “I’m going to lose my virginity tonight. Any tips or advice?”

42. Peer Support “Hiya I could do with some help and tips on how 2 stop self-harming. Because I’m finding it really hard at the moment with all the exams and it doesn’t help that my mum is mad at me because I have kept that I’m bi away from her because she said it was a phase. I’m just so confused and self-harming is so tempting. Help please I need any tips. I’ve tried using my punch bag but I can’t seem to get it out of my head.” • On an internet forum moderated by other young people. The first response was flagged by another user who indicated they were concerned and asked if a moderator could help • A forum moderator responded: “Anything more (support) that's needed should be obtained from a trained professional, not another young person on the internet - that is all FORUM can offer at the moment and doesn't claim to offer any more.”

43. Summary of challenges • LGB young people face issues offline which contribute to poor mental health. They may not receive adequate advice, information and guidance on issues relevant to them at school and from health services. • They face barriers to accessing mental health support. • They use the internet to access support and fill gaps in information. • There is a lack of professional, safe and accessible online support. • There is a potential for intervention at all of these points. • For more information, highly recommend: Where to Turn, PACE, 2010

44. Good practice: NHS Choices

45. Good practice: Beat Bullying

46. Good practice: ChildlineMessageboards

47. Online prevention of poor mental health • Static content: • Signposting to support (like phone lines and offline services) , especially crisis support • Positive information about sexual orientation • Links to appropriate LGB websites • Information for professionals on suicide and LGB young people • Moderated user forum • 2. Interactive content (for example email support, livechat, online counselling): • Clear safety protocols • Out of hours availability • Fast response • Staff/volunteer training • Consultation with LGB community • PACE is developing an out of hours online support service for LGB&T community

48. Recommendations: schools & youth groups • Ensure young people able to access appropriate LGB websites • Ensure staff working with young people know websites to direct lesbian, gay and bisexual young people to • Promote websites for LGB young people in spaces that young people use • Use internet to allow young people to anonymously report bullying in school or in wider community • If your service has facility to host a forum for young people ensure this is adequately moderated

49. Recommendations: Support providers • Ask websites for LGB young people to promote your service and to display contact details • Consider offering online support services • Display lists of LGB services or times when LGB worker available. Include contact details and crisis contact details • CAMHS websites could make specific references to openness of service, including to lesbian, gay and bisexual young people • Promote support services through social media • Ensure your website makes it clear that your offline services are LGB inclusive such as by publishing policies; having LGB info on website.

50. Websites www.pacehealth.org.uk www.mindout.org.uk www.iRelate.org.uk www.metrocentreonline.org www.youngstonewall.org.uk 08000 502020