Building a public health approach to health and social care integration: the story so far

 

 

We’ve been working on articulating a public health approach to health and social care integration for a couple of months, and people have asked how we’re getting on.

 

Things have moved on quickly since we started before Easter

 

  • We are awaiting our consultant in public health whose role will be to lead on public health approaches to health and social care full time joining us

 

  • We have created a health psychologist post to work on embedding psychological approaches to patients and carers (resilience, self-management, coping) and staff (effective working with users and carers) based on what psychology has to offer

 

  • We are putting psychology posts into drug and alcohol recovery services and into thriving families

 

  • We are putting workforce redesign and psychology skills into home care and re-ablement work

 

  • We have started a joint workstream across our CCGs, NHS and local authority on self-management

 

  • With CCGs we have jointly assessed and re-negotiated our “core offer” of advice and support to them, and both ccgs are looking to employ additional public health project roles (clinicians who can be trained in public health practice) to deliver pathway work etc

 

  • We are working with CCGs to establish clinical public health leads in every locality, whose role will be to support prevention and integration

 

  • We have started to articulate what a whole system strategic approach to prevention looks like in support of integration, but this is early days

 

 

The self-management workstream

 

We held a workshop recently where we agreed that there were four main actions coming out of the self-management event:

 

1)     Embedding behaviour change into existing pathways e.g. Map of Medicine

 

2)    Getting a single comprehensive source for details of resources for clinicians, carers etc

 

3)    Training for the wider workforce e.g. Motivational Interviewing

 

4)    Handing this as a workstream to our forthcoming Behavioural Sciences Unit to deliver with a view to:

–          Developing a network of Behaviour Change Champions across both sides of the county

–          Training of practice staff in Behaviour Change principles and/or MI

–          Ongoing support for Champions to ensure skills are put into practice

 

I’ve put the slides from this on slideshare so people can see where we are at.

 

We need strategies to keep people with existing disease at optimum levels of health and functioning. That needs a combination of good clinical management, supporting people to be resilient and self-manage, and ensure social support and coping are put to the top of our agenda. And it needs professionals to learn from people with long term conditions about what works for them. In some ways I have learned more about living with long term conditions from caring for my mother with diabetes, my father with heart disease and my own experience of overcoming cancer (a typically healthy Scots working class family there) than I did from any training.

 

Partners are understandably seeking high impact interventions to   enable this to happen, ensure that health and social care integration is            effective, ensure that resource is well spent, and achieve these           challenging outcomes. We have set up a working group comprising a range of colleagues and partners from across NHS, local authorities and third sector.

 

 

The JSNA has identified that Health and Social Care Integration is a significant priority for Hertfordshire and this work is about identifying the Public Health role in supporting this.

 

 

Conceptualising the role of public health and the commissioning      cycle

 

Public Health is often conceptualised as working across three domains of activity ; Health improvement, Health Protection and Service Quality. We’ve spent some time looking at these and we believe these three domains provide a significant opportunity for Public Health to play its part in Health and Social Care Integration. The opportunity is to ensure that work across the three domains considers how it can be             done in a way that supports health and social care integration agendas. At a high level this looks like:

 

i)             Health Improvement – commissioning public health services in such a way that they support integration (Example. ensuring joined up pathways for exercise referral include secondary prevention and rehabilitation in the community.) (Example: developing psychological approaches to self-management and rolling these out.)

 

ii)            Health Protection – ensuring robust infection control in residential care, ensuring our population is effectively covered by screening, immunisation and vaccination to reduce the burden of avoidable disease on health and social care systems including staff seasonal ‘flu vaccination

 

iii)           Service Quality – provide effective needs analyses for commissioners, provide advice on effective interventions and where evidence is silent provide advice on what interventions are likely to be effective, support development of outcome and evaluations.

 

3For Public Health we have conceptualised a cycle of public health           delivery which is shown below. This has been developed by using the approach described since 2012 and it is suggested that this provides a useful conceptual tool for understanding the public health role both in its direct commissioning function (e.g. effective commissioning of drugs and alcohol services) and in it supporting function (supporting commissioners in effective mental health commissioning, for example.)

 

Figure 1.

 

 

 

 

Key tasks for public health in health and social care integration

 

From this come some high impact tasks for Public Health in supporting health and social care integration:

 

 

  1. Providing analyses of data which combine epidemiology with analysis of system and patient data to produce an understanding of what the main issues are including intelligence on patient flows, pressure points, rates and issues. So for example we are working currently on mental health and on alcohol as just two examples.

 

  1. From the analyses identify the system and patient population issues causing most challenge to health and social care integration, in keeping people out of hospital

 

  1. Search and appraise evidence to identify possible candidates for commissioning to address these issues

 

  1. Where evidence is silent, support the development of interventions likely to work from existing theory and evidence

 

  1. Support development and implementation of integrated pathways across health and social care

 

  1. Commission public health services (e.g. weight management) in such a way that they contribute to the integration and out of hospital agenda

 

  1. Work to develop predictive models and tools to enable clinicians and commissioners to identify those most likely to experience avoidable hospital episodes

 

  1. Identifying the five most important things each CCG locality can do in its commissioning strategy (this is currently underway.)

 

Articulating a delivery model

 

Our working group has identified the following delivery model to work on health and social care integration

 

 

Stage of PH Delivery Model Examples of work underwayMore needs to be done and we have the opportunity to be more systematic
Understand what’s needed
  • JSNA
  • Detailed needs assessments on themes (e.g. mental health underway)
  • CCG locality reports are being produced
  • Locality profiles
  • Health outcomes profile

 

Identify what works
  • Evidence review
  • “best buy” interventions (see below)
  • Prior Approval and IFR support
Understand players, roles contributions
  • A working group between CCGs, Children, HCS and Public Health has been convened on Health and Social Care Integration
Good implementation
  • Developing behavioural science programme (developing interventions to roll out for self-management)
  • Working group to help ensure intervention fidelity

 

Right intervention, right delivery mechanisms
  • Public health contribution to commissioning plans
  • Kicking off the co-production work
  • Behaviour change etc training
  • Sexual health transformation
  • Health check improvement programme and developing services to enable GPs to refer people at risk
  • Pathway development (Obesity)

 

Evaluate outcomes
  • Helping develop outcomes before commissioning starts for programmes

 

 

What specific interventions are likely to work in integration

 

The working group set out to answer the following questions about specific interventions.

 

  1. What interventions will have the highest impact in integrating health and social care?

 

  1. What interventions will help keep and manage older people with multiple health problems in the community?

 

  1. What interventions will help keep adults with long term conditions in the community?

 

We are still working on this but have identified some quick high impact actions. We have chosen interventions which, from the available evidence, seem to be effective or show promise at integrating health and social care. The evidence for most of these interventions is of low quality because randomized designs are not common in social care. These           interventions have been selected based on review of existing evidence and using the model of evidence appraisal suggested in the Kelly et al 2013 paper on a deductive model for public health[1]

There is good evidence for lifestyle management and also for assertive management of risk factors such as

 

    1. effective prescribing of drugs to control blood pressure
    2. effective prescribing of drugs to reduce cholesterol
    3. supporting behaviour interventions (exercise on referral, diet, self-management, motivation)
    4. uptake of smoking cessation services
    5. increased anticoagulant therapy in atrial fibrillation
    6. improved blood sugar control in diabetes

 

The importance of these primary and secondary prevention initiatives should not be underestimated in ensuring people can remain stable in the community and less in need of complex services. There is also good evidence for cardiac rehabilitation, falls prevention and stroke pathways. We believe these are important foundations to make integration work.

 

An area which needs significant further investigation is competencies and skills in staff across NHS, social care, independent and third sector. There is some evidence to suggest that staff with these skill sets do    better in keeping people in the community:

 

  1. Problem solving approaches
  2. Hybridisation of skills (e.g. social care staff who can do some basic clinical procedures)
  3. Supporting and motivating people effectively to cope, self-manage and develop skills and strategies for this
  4. These need to be supported by pathways wherever possible

 

 

The Interventions lists so far to support effective integration

 

Based on our discussions and early searches of evidence and experience from elsewhere, we are working on typologies of suggested high impact interventions to support health and social care. We are still working on these and will develop these further, but here is the very earliest cut of the Adults with Long Term Conditions and Older Adults tables so you can see our early thinking.

 

 

 

Adults with Long Term Conditions

 

Topic High Impact Action Evidence
Early preventive work in newly diagnosed and those with established disease Pathways in newly diagnosed and existing diagnosed for healthy lifestyles (physical activity, smoking cessation, weight management) combined with self management training and clinical management of diagnosed disease 

 

A further column providing the evidence citations or basis of judgement will be placed here
System pressure points / areas where practice could reduce avoidable admissions Individual care plans for people with history of repeat admissions before they go into hospital
Predictive modelling of those whose risk factors indicates repeat admissions likely
Aggressive management of clinical risk factors and care plans of those whom predictive modelling has suggested are likely to be repeat admissions
Structured management guidelines and pathways in residential and nursing care to avoid emergency calls unless necessary
Better management of common UTIs and dehydration in residential and nursing care to avoid hospital admissions
Structured and early discharge planning
Care home review team to put in place plans to prevent re-admission
Better use of voluntary sector in home from hospital and out of hours
Stroke Stroke pathway including early supported discharge
Self-Management and Resilience Self management and resilience for all patients but especially those with asthma and COPD 

Use of multiple platforms for this (e.g. face to face, film, group, online)

Cardiac care Cardiac rehabilitation pathway phases 1 – 4 including in community
Aggressive management of clinical risk factors in highest 10% of repeat admissions across all long term conditions

 

 

 

 

 

 

0lder Adults

 

Topic High Impact Action Evidence
Preventing admissions Falls prevention – multi factorial assessment and early intervention A further column providing the evidence citations or basis of judgement will be placed here
Self management and health improvement (diet, basic exercise, social contact) in older people at risk of re-admission based on analysis of factors
Assistive technology – telecare and teleheath
Virtual wards and step up beds
Moving people from admission into their own home and reducing likelihood of re-admission Virtual Wards
Community geriatrician and enhanced dementia support
Multi- Agency care
Structured discharge plans
Self-Management and resilience
Care home review team to put in place assertive management strategies in care homes to prevent admissions
Increased provision of step up beds

 

 

 

This work is still in progress and our next step is to work further on these, and collaborate with public health England about where we want to go.

 

[1] A.J. Fischer, A. Threlfall, S. Meah, R. Cookson, H. Rutter, and M.P. Kelly. The appraisal of public health interventions: an overview J Public Health (2013) 35 (4): 488-494 first published online August 29, 2013

Advertisements

Applications of resilience: public health approaches to victims of hate crime

Working with victims from reporting to readjustment

 

I met our victims commissioner for the  Police and Crime Commissioner for the first time last week. He came along to our Public Health Board. He asked why I have a small team in Public Health embedded in our joint police/council community safety unit working on offenders but no mention of victims. And actually he’s right. This is an area we need to do more on.

Back in the day I was at Nacro I wrote a toolkit for the Home Office on hate crime, and another one on homophobic crime especially, working with the amazing Professor Ian Rivers now at Brunel.  Other colleagues worked with me on crime and disabled people. Some of the work I did at Nacro on health and crime is accessible here.

The resource manual Tackling Hate Crime produced by the Association of Chief Police Officers, London. 2000 did some great stuff in its time. But actually we do need to look at this afresh from a public health perspective. What I’ve done here is to summarise where the literature and practice seems to be at from my experience and knowledge. At some point I will try to properly write this up (anyone wanna help? then email me jim dot McManus @ Hertfordshire dot gov dot uk.) But this is offered to help practice.

I’m going to use LGBT hate crime as an example for the rest of this post, but I think there are applications here across all types of hate crime.  I’m not going to focus on bullying in schools because there is quite a lot out there, just check out Ian River’s site or Stonewall  and this post can be read in conjunction with that. Similarly for faith schools there is the work done by the Church of England recently

There are, it seems to me from the growing consensus in literature on hate crime, several public health tasks:

  1. Ensuring the Joint Strategic Needs Assessment accurately reflects community and agency intelligence on hate crime
  2. Defining and finding and encouraging reporting of cases
  3. Ensuring victims are supported effectively in the immediate aftermath, because this will have long term consequences for helping or hindering adjustment
  4. Ensuring consistent standards of practice are in place

The initial approach: seeing victimisation in lifecourse perspective

Working with victims of Hate Crimes is something which, at first sight, can feel awkward and difficult for many. It is easy to assume that because the vcitim is lesbian/gay/bisexual or transgendered that there will be specific issues. While this is often the case, there is usually a core of symptoms and experiences common to victimisation. Some of these can be evidenced by the fact that victims of hate crime may often have symptoms analogous to, or actually experience, Post Traumatic Stress Disorder. There can be significant long term sequelae from experiencing hate crime.

If reporting and response mechanisms, however they are adopted, are to succeed, there is a need to ensure that people who identify themselves as having been victimised are treated and welcomed appropriately and sensitively, and encouraged to make the journey towards resolution. There are, therefore, from a public health perspective short term and long-term goals which anyone working with victims needs to address.

This assumes that there are two roles to supporting victims in the short and long terms, “reporting” and “supporting”.

 

  • Reporting involves making a formal report and commencing the appropriate action to investigate, gather evidence, monitor, etc.
  • Supporting is the process of enabling the victim to make sense of the incident, to seek and offer appropriate help (informally or professionally), to readjust and come to terms with the incident, and rebuild their life.

 

In the immediate term after an incident of victimisation, it is likely that the reporting and supporting process will be provided at the same time, at least initially. This will require appropriate training of those who receive reports.

In the medium to longer term after an incident, it will be necessary to identify carefully whether and when to offer referral on to skilled sources of help, and to offer this sensitively.

Where a report is made by someone a considerable period of time after an incident (e.g. six months or more), there is still a need to ensure that the report is taken sensitively and confidentially, and that appropriate onwards referral for support is offered. This is especially the case where someone has not sought help before. “Flashbacks” to the event, emotional distress and other post-traumatic stress symptoms can often be seen at this point. If the person receiving the report is unsympathetic the person reporting may not seek further help and may present later with more significant emotional distress.

 

Work with rape and sexual assault victims, work with victims of racial hate crime and some projects in existing areas demonstrate some very good practice on work with victims. Lothians and Borders, the Metropolitan Police, Northumbria, Greater Manchester and Hampshire constabularies have all for long periods of time trained police officers to respond appropriately to victims and support them while obtaining necessary reports and statements. Manchester, London, Edinburgh, Hampshire and Lancashire all provide the option of using agencies external to the police where people can report and seek help. Victim Support and Citizens Advice Bureaux both have policies on working with diversity and may be sources of help and suppor. Local lesbian and gay switchboards may also prove useful sources of support, but in some areas are likely to need training to be able to deal fully with these issues.

 

The short-term goals for working with someone who has very recently been victimised or assaulted and is presenting to report the crime or share the experience are:

 

  1. To be able to report the experience and have it taken seriously in a non-judgmental atmosphere
  2. To be listened to without judgment or fear of retribution on moral or legal grounds
  3. To have someone (e.g. a friend or partner) present and treated as a significant other if they wish.
  4. To be assessed for extent of physical, psychological and emotional trauma and supported in seeking appropriate help
  5. To make necessary practical arrangements (e.g. escort home, reporting missing wallet, credit cards, property etc.)
  6. To have an opportunity to tend to personal care and hygiene after any necessary medical or forensic examinations
  7. To be able to feel safe to express or not to express emotional response, as the person chooses
  8. To make arrangements for, and have any dependents informed, should they wish
  9. To be taken seriously.

 

More detail on these goals is written into Table 2 below.

 

These goals could be written into standards and procedures for each agency. Each agency should also assess what training is required for staff and volunteers.

Local Authorities and Police Authorities should consider what issues arise in light of s.17 of the Local Government Act 1998. Local Authorities may need to adopt diversity policies where these do not exist and train staff likely to deal with victims (e.g. housing front-line staff, social services staff, etc.)

The issue of friends and partners needs specific attention. One thing common to both victims of homophobic hate crime and disability hate crime (especially hearing impaired and deaf people) and some faiths is the very strong social relationships. Kinship and family is not just biological. The nature of kinship in the lesbian and gay community alone  is such that friendships can be extremely important relationships[1]. It is important that friends and partners are informed about what is happening and that the victim of crime is able to have them included or not, as s/he wishes.

 

We can actually derive some standards for long-term outcomes of victimisation, which, while in this context written for an LGBT community, are actually pretty applicable across hate crime categories. I’ve adapted these with kind permission of John Wiley & Sons (Chichester) from Evosevich, J.M. and Avriette,M. (2000) The Gay and Lesbian Psychotherapy Treatment Planner. Chichester : John Wiley & Sons. ISBN 0-471-35081-8

 

Long Term Behavioural, Social and Cognitive Goals

 

  1. Physical recovery from trauma/injury and appropriate rehabilitation (e.g. physiotherapy)
  2. Eliminate intrusive thoughts, nightmare and memories
  3. Resume social activities and employment
  4. Increase feelings of confidence and satisfaction with personal identity
  5. Appropriate preparation and support for any court appearances (or restorative justice work) to ensure that the victim does not experience a regression into self-victimisation or other harmful responses to the incident
  6. Enhance personal awareness of safety and ability to protect self
  7. Increase trust in reporting and enforcement systems
  8. Return to the level of emotional and social functioning before the assault.

Suicide and self-harm remains a risk from a public health perspective which needs to be prevented. While from a US perspective, this recent report prvides some valuable insight

 

Using this work

These suggested good practice standards could form the basis of action in any joint work between Police and Crime Commissioner, Public Health and other agencies.

I’ve developed some definitions which could be regarded as standards here using Evosevich and Avriette as a springboard, and synthesising the literature from Ian Rivers and a range of others, to provide what could become a victims response tool for LGBT hate crime, and other hate crime, from a Public HEalth Perspective

There are several sections to this:

  •  getting a clear set of definitions
  • some short term goals which should help the trajectory towards response and readjustment
  • some suggested standards for counsellors/responders

 

 

Table 1 : Behavioural Definitions

This table is intended to help anyone supporting a victim of hate crime to define some of the key problems and issues experienced by the victim.                       

This list can then be used to look at whether people might want referral to psychological or other support, or how serious the experience was.

Number Behavioural Definition of being a Hate Crime Victim
1 Self-report or account by others of physical assault by stranger because of sexual orientation
2 Self-report of being forced to engage in sexual activity with another person
3 Bruises, cuts, abrasions or other trauma
4 Physical pain, wound, disability, fracture or other physical problem requiring treatment
5 Recurrent, intrusive and disturbing thoughts, dreams and memories of assault
6 Blaming victimisation on characteristics of oneself (e.g. being camp, weak because of sexuality, etc.)
7 Restricted range of affect (i.e. reducing or restricting ability to show affection, emotion, etc to friends/family/partners)
8 Prolonged disturbance of mood and affect (e.g. depression, irritability, anxiety, apathy, withdrawal)
9 Avoidance of social activities (e.g., work, activities with partner/friends or family)
10 Subjective sense of numbing, detaching or absence of emotional responsiveness
11 Avoidance of people, places and activities that are reminders of the assault
12 Difficulty sleeping, poor concentration, restlessness

 

Table 2 : Short-Term Objectives in Detail

This table is intended to develop further the short-term goals for the victim identified above both for reporting and supporting agencies. It is adapted, with permission, from Evosevich and Avriette[2].

 

Short-Term Objective for Victim Kind of Intervention from Counsellor or WorkerImportant : some of these interventions need skilled, trained and supervised people
q  Give an accurate and emotionally honest description of the assaultq  Identify and express any guilt, shame, anger, helplessness and/or self-blame associated with the assault q  Actively build the level of trust with the client in individual sessions through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/her ability to identify and express feelings.
q  Comply with a comprehensive evidence gathering process (physical, forensic, information, report forms, etc) to assure all relevant evidence is gathered and no serious injuries have been sustained and not diagnosed or treatedq  Report results from physical examination and pursure any medical treatment necessary q  Gather a history of assault including time, location, assailant(s), police involvement, etcq  Assess depression and/or suicidal tendenciesq  Encourage verbal expression and clarification of perception of facts associated with inciden

q  Appropriate referral to medical or dental etc support, and Genito-Urinary Medicine clinic if sexual assault

q  Understand and express how assault has impacted function in social, work and family/partner situationsq  Express an understanding of the psychological impact of the traumaq  Seek reading materials/support groups etc q  Explore feelings associated with the assaultq  Assist victim in identifying the negative impact that the assault has hadq  If appropriately qualified, administer a scale such as the Clinician Administered PTSD Scale (Blake et al, CAPS) or the PTSD Symptom Scale (Foa et al, PSS) to assist with diagnosis and to determine severity of symptoms and impairment. Construct therapeutic goals around this.

q  Support in finding reading materials, support groups, specialist counselling etc.

q  Understand effects of flashback etc reactions to incident and prepare for periodic “rough times” after incident.q  Identify any pattern of blaming self for assaultq  Obtain support from friends, partners and family members

q  End self-blame and place responsibility on perpetrator

q  Challenge negative self-talk and replace with more realistic beliefs

q  Educate about common reactions to assault, e.g. anxiety, flashbacks, avoidance, self-blameq  Help client find coping strategies for when this happens (e.g. friends, relaxation, etc) Identify friends and family members who are supportive.q  Explore solutions for creating support in friends, partner and family members

q  Explore and supportively confront client regarding self-blame and assist in placing responsibility on perpetrator

q  Educate client about challenging unrealistic self-talk and replacing it with realistic self-talk.

q  Assist in exploring restorative justice measures

q  Understand and express how societal homophobia and the perpetrator’s background of hate created the climate for the victimisation, not being gay or lesbian q  Educate client about the nature, incidence and severity of homophobic crime.q  Explore and confront self-blame
q  Be clear on advantages and disadvantages of prosecuting q  Ensure police give support and advice in time up to prosecution, advise getting sympathetic lawyer/advocate
q  Reduce anxiety q  Arrange avoided situations into an anxiety hierarchyq  Develop strategies to deal with these and reduce anxietyq  Practice relaxation and deep breathing techniques
q  List situations, places and people being avoided q  Arrange avoided situations into an anxiety hierarchyq  Develop strategies to deal with these and reduce anxietyq  Encourage discussion about these and confrting them with a supportive friend, partner or family member.
q  Reduce likelihood of future victimisation q  Encourage self-safety strategies (see reporting section of toolkit), attendance at self-defence classes, etc.
q  Challenge irrational fears about being re-victimised q  List situations being avoided and develop self-safety strategyq  Explore sources of fear and develop strategies to deal with this
q  Ensure rational fears about being re-victimised and fed into community safety process q  Reporting to police, community safety forum or through lesbian and gay agency
q  Dealing with problems of faith, religion, etc. q  Ensure availability of sensitive support. The Lesbian and Gay Christian Movement, Quest, Gay Jewish, Muslim and other groups have lists of sensitive and supportive clergy and support groups.
q  Ensure unhelpful coping mechanisms and relapses are dealt with and that more helpful coping mechanisms are found. q  Explore for unhelpful coping mechanisms such as self-blame, relationship avoidance, excessive spending, delusional behaviour, entertaining suicidal thoughts, putting personal safety at risk, etcq  Explore for relapse into any previous risky health behaviours e.g. unsafe sex, excessive alcohol or drug use, smoking, etc.q  Explore for relapse into previously terminated behaviours such as smoking, drugs, etc

 

Life Reconstruction or Deconstruction?

Sometimes a victim of hate crime will enter on a period of re-evaluating their entire life as it currently is. This can sometimes be a constructive process but is equally often a self-destructive and self-blaming reaction to trauma. Skilled support is necessary when this occurs, especially because relationships of all kinds can be severely damaged or terminated during this. At a lower level, any patterns of dependence (on people, possessions, faith or ideas) or addictions (smoking, illegal drugs etc) may be tackled. Sometimes people decide to lose weight or try to change their body appearance, etc. It is important to understand the context of where this is coming from and why. If it is an avoidance response to victimisation, it can block readjustment. If it is a reaction to self-blame or self-hatred, it can become highly destructive. Even if it is a genuine response to things the person feels are wrong (e.g. giving up smoking and losing weight and dealing with an unsatisfactory relationship), taking on too many things in the period after victimisation could have serious consequences for physical, mental and emotional health. Helping the person look realistically at this, encourage development of a “now, sooner, later” plan for their life and encourage getting expert help are all helpful responses to this.

 

Offering Skilled Therapeutic Support

A developing consensus in much of the research and published literature, and particularly in the British Psychological Society guidelines on working therapeutically with LGBT people makes clear that it is not enough for someone to say they are not homophobic in order to work with LGBT victims. Therapists, counsellors and crisis support people working with LGBT people who are victims need to be accepting of the social, cultural and emotional perspectives and issues of the victim. This can raise difficult issues for the worker and for the victim.

We need to consider what support is offered to someone who has been victimised. As can be seen from the goals above this will inevitably involve someone with appropriate skills and experience. It is advisable to consult an agency like PACE (www.pace.org.uk) about standards or the local psychology services. There needs, however, to be some kind of minimum standard to ensure that:

 

  1.  People who are victimised are treated supportively
  2.  Appropriate action is taken to enable the victim to adjust, heal and move on and deal with the perpetrator
  3.  The reputation of the reporting system and enforcement is not tarnished by allegations of poorly skilled staff or, even worse, homophobic or other harmful reactions

For that reason the following principles are offered as some training standards to consider:

 

FOR FIRST REPORTING AGENCIES AND PERSONNEL

 

  • Training in basic issues on homophobia etc as laid down in the training programme in the toolkit
  • Training in reporting procedures
  • Training in first-aid
  • Knowledge and awareness of procedures and sources of help and support
  • Awareness of sexual and mental health issues of victimisation
  • Refresher training annually
  • Availability of skilled supervision and personal support

 

Other Psychological Problems and Issues

There are a range of other problems which can be encountered when doing therapeutic work with the victim of hate crime, from anxiety to multiple loss, relationship issues, sexual dysfunction and family issues.

The American Psychological Association has a good LGBT resource section which provides a range of information and tools.  Equally there are some recent tools on responding to transgender victims of sexual assault which may be helpful.

I do get people asking me about conversion therapy and whether this can help. The developing consensus on this is it can do much more harm than good, and a joint British statement on this from the leading therapeutic and psychological organisations would strongly suggest this is an approach to avoid.

 

 

References

 

[1] McManus,J and Kelly,B (1994) Assessing Kinship Networks. Care Weekly, 1 December.

[2] See also Herek, G. and Gillis, J. (1999) “Psychological Sequelae of Hate Crime Victimisation among Lesbian, Gay and Bisexual Adults.” Journal of Consulting and Clinical Psychology. And McManus, J and Rivers,I (2001) Without Prejudice : A Briefing for Community Safety Partnerships. London : Nacro.