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Section 3. Supporting students experiencing mental health difficulties

Please click on the links below to jump to the beginning of each sub-section:

3.1. Assessment of needs
       3.1.1. Declaration of needs prior to entry
       3.1.2. Identification of needs post entry
       3.1.3. Assessment of needs within the institutional remit
       3.1.4. Assessment of needs which are outside the institutional remit
       3.1.5. Where recognition of needs is denied
3.2. General guidelines for staff supporting students with mental health difficulties
       3.2.1. Determining whether there may be a mental health difficulty
       3.2.2. Approaching the student
       3.2.3. When a student does not want to talk
       3.2.4. When a student does want to talk
       3.2.5. Handling a crisis situation
       3.2.6. Confidentiality
3.3. Specific support arrangements for students with mental health difficulties
       3.3.1. Learning support
       3.3.2. Examination and assessment
       3.3.3. Fieldwork
       3.3.4. Careers advice
       3.3.5. Accommodation
       3.3.6. Financial support
       3.3.7. Student support services
3.4. Role of Students' Unions
3.5. Liaison with external agencies
       3.5.1. Local health services
       3.5.2. Voluntary organisations
3.6. Appendix: guidelines for specialist support staff on using a 'framework of questions'
       3.6.1. Using a 'framework of questions'
       3.6.2. An example of a 'framework of questions'

3.1 Assessment of needs

The assessment of needs is the starting point in the process of supporting students with mental health difficulties. The first step is the identification that there are difficulties. This identification may come from a declaration prior to entry or may often arise post-entry:

3.1.1 Declaration of needs prior to entry

  • Some students may approach the institution on their own initiative to discuss their needs or someone may have done so on the student's behalf (e.g. tutor, mental health service provider etc) with the student's knowledge and permission. A declaration of a mental health difficulty may also be made on an application form.

  • In all such cases this gives the opening to invite the student to discuss any needs they may have in relation to their mental health difficulties. Giving this opportunity, preferably in good time before the start of the course, is essential.

  • The invitation must be given in such a way as to diffuse any fears on the part of the student as to how this information may be used. It must be made clear that the institution intends to work with the student to define their requirements, if any, and that the discussion and any information imparted will only be used in the student's sole interests and with their full knowledge and permission, including any terminology used about them.

  • It should not be assumed that, if a mental health difficulty is declared, there will always be needs relevant to student life or to the institution. A student may not wish any special arrangements to be made or even discussed.

  • Declaration can be encouraged by the use of pre-entry literature etc which makes positive statements around the institution's commitment to student mental health in general and towards a non-stigmatising community (see also section 6.2).

  • For those students with mental health difficulties who are making the transition from FE to HE, needs may have already been identified and addressed at FE level. Effective planning around transition from FE to HE in such cases maybe critical to successful progression and retention. Collaboration between FE and HE, particularly where there is local progression, is particularly effective in encouraging students to declare their needs on application to HE, with the assurance of support, advice and relevant information (e.g. on academic expectations, change in culture, practical and financial support) from both sectors.

Reference: 'Preparing Students for Transition from FE to HE', Inclusive Learning Research Network Project (details: enquiries@LSagency.org.uk).

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3.1.2 Identification of needs post-entry

  • Many students will not have declared any mental health needs at application or prior to entry. Particularly because of the continuing problems over stigma and mental health in society, this is very commonly the case.

  • The first time that a possible mental health difficulty or history of previous mental ill-health is identified is often in a chance conversation after entry or in the wake of a particular 'crisis' or time of stress (e.g. at examination time). There are also often cases when fellow students detect a problem, which they bring to the attention of someone in the institution.

  • In all such cases a protocol needs to be followed (see section 3.2 ) which respects the student's right not to discuss their experience but does give the opportunity for them to do so. This may be much easier in the pretext of a regular meeting (e.g. with a personal tutor) and this therefore works best where there are already good pastoral arrangements in place. Sometimes a simple question, such as "how are things going?" may be all that is needed to give a student the confidence to identify needs.
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3.1.3 Assessment of needs within the institutional remit

  • If a declaration about mental health difficulties is made at any stage, this is the opportunity to assess whether the student has any needs which the institution should meet. A detailed assessment of such needs would normally be carried out by a member of specialist support staff with appropriate training and experience. Specific areas which might be discussed with the student could include:

  • Often all that is needed is some awareness of possible times of vulnerability, e.g. times of stress, changes of medication etc.

  • Any special arrangements, for instance during examination time, can best be discussed and agreed in advance and may require few major alterations.

  • Even a student with more significant mental health difficulties may not wish to have any particular concessions or arrangements in respect of their studies and student life, beyond awareness by appropriate personnel and a degree of flexibility at particular times. They may have their own support network through a CPN (Community Psychiatric Nurse), for instance, and wish to keep this separate from their student life.
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3.1.4 Assessment of needs which are outside the institutional remit
  • With the exception of specific professional support services, the assessment of needs in terms of mental health difficulties is only within the normal institutional remit when the needs are directly connected to the student experience. However, the institution may be the first place where mental health needs are identified. This could well happen where an individual experiences their first episode of mental ill-health on becoming a student.

  • In such cases a referral to professional expertise may be critical. The first point of contact would normally be an in-house support service such as the counselling service or health service, which might then choose to refer to external mental health services. This is where good working links with external agencies are crucial (see section 3.5).

  • The procedure above assumes the full agreement of the student and it is always preferable that the student takes maximum responsibility for arranging appointments etc unless they specifically request someone else to do so. If a student refuses to be referred that has to be respected. Normally the only exception is where there is a serious risk to the student's safety or that of others (see section 3.2.6)

  • Detailed assessment of needs should not be undertaken outside a professional remit or without appropriate expertise. For those working directly in the area of student support, to whom an initial referral may be made, the use of a 'framework of questions' to identify appropriate action or further referral may be helpful (see appendix, section 3.6).
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3.1.5 Where recognition of needs is denied
  • Research and experience shows that a significant number of students who experience mental health difficulties are extremely reluctant to seek help or accept recognition of needs.

  • Measures to improve the general attitude to mental health issues (see section 5 and section 6) and the use of specific approaches (see section 3.2) may help, but it must be accepted that there will be some who may not be reached in terms of the support available.

  • An institution which has taken all reasonable measures in such areas as mental health awareness raising, staff training and development of appropriate support services and protocol still has limits of responsibility.

  • It can be a cause for considerable concern for staff or students who find themselves in the position of being unable to help or intervene, especially where assistance has been offered and refused and a serious incident related to mental health difficulties occurs. Training and information on boundaries and referral is critical in this context, as well as the provision of appropriate institutional support for those who find themselves in a supporting role (see section 5).

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3.2 General guidelines for staff supporting students with mental health difficulties

Some general procedures and protocol can be used by any member of staff who is concerned that a student has mental health difficulties and may need support. The purpose of this section is to give general, basic guidance on procedures, referral, handling a crisis and confidentialty. For staff with a specific responsibility for student support, there are more detailed guidelines on the use of a 'framework of questions' as a tool for supporting students who may have mental health difficulties in the appendix, section 3.6. Section 3.3 is concerned with more specific support arrangements in different areas of the student experience.

3.2.1 Determining whether there may be a mental health difficulty

Section 3.1 considered assessment of needs further to declaration or identification of mental health difficulties. However, students do not always express problems directly or ask for help. Sometimes they feel embarrassed or are concerned about the consequences of telling someone in their department or they hope the problem will go away, or they are unaware that they have a problem.

It may be useful to consider some of the following questions:

  • Has the student told you they have a problem?
  • Have there been any significant changes in the student's appearance? (e.g. weight loss/gain, decline in personal hygiene)
  • Does the student smell any different (e.g. can you smell alcohol or cannabis)?
  • How does the student sound? (e.g. flat, agitated, very quiet, very loud)
  • Has the mood of the student recently changed a lot from your previous experiences with them? (e.g. moods very up and down, miserable, tired a lot)
  • Have others (house mates, friends, other colleagues) expressed concern about the student?
  • Have there been recent changes in the student's behaviour, college work and/or sociability?(e.g. doing too much work, not socialising as much as usual, withdrawn, not attending lectures or meeting deadlines)
  • How long has the student been feeling or behaving like this (everyone can have bad days, but it is when days turn into weeks and months that there may be a problem).
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3.2.2 Approaching the student

If the answers to any of the above questions (section 3.2.1) are yes, the following guidance may be useful:

  • Do not avoid the situation or pretend nothing is wrong, as this could make the problem worse and persist for longer.

  • Approach the student in a sympathetic and understanding way. Remember to be sensitive to issues relating to sexuality, race, religion, culture and gender.

  • If you simply ask the student how they are, this may provide them with an opportunity to discuss their concerns with you. The situation may only require empathetic listening.

  • Be prepared to listen and give some time if you can. If there are constraints on your time, inform the student from the start that this is the case. Avoid using unhelpful comments like 'pull your yourself together'.

  • Being open and honest with the student in your initial contact will help to develop trust. Very often help is not sought because the student may be concerned about the consequences of telling someone. If you feel you need to tell someone else, try to obtain the student's consent. However, in some situations, you will be able to talk about the situation to another person and ask their advice, without revealing the identity of the student.

  • If you feel you can support the student, do consider whether you have enough time and/or the skills. Try not to offer help that is beyond your role. Be clear about your role and its boundaries. Everyone has something to offer, but it is vital that we are all aware of what we can realistically do and are qualified to offer. Consider also, any potential conflict of your role and whether you have someone to consult or give you support.

  • The student may not always identify that they have a problem or may not want to acknowledge it. Try not to humour the student by pretending to agree that there isn't a problem if it is clear there is one.
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3.2.3 When a student does not want to talk
  • It may be extremely difficult to help someone with a problem unless they are ready to admit they have one. If the student is not ready to accept help or talk about their problem, do not ask insensitive or intrusive questions. Always respect the right of the student if they do not wish to discuss things. Offer an open invitation to the student to come back and talk to you in the future. Continue to ask how they are and reiterate that they can talk to you, when you see them again.

  • However, if you are still very concerned about a student who has refused help, speak to your head of division or someone from a specialist support service for advice.
3.2.4 When a student does want to talk
  • If the student does talk about their problem with you, try not to give advice that is not within the boundaries of your role, but rather listen and encourage the student to seek the appropriate help. Try to recognise what you can realistically do and whether there is a more appropriate person to deal with this. It is not always possible to identify which source of help would be most appropriate. However, it is important in the first instance to refer the student to somewhere that is acceptable to them. A further referral can always be made later.

  • Express your concern but remember you are not a therapist or a counsellor. It is not your responsibility to solve the problem and if you feel you are unable to suggest the way forward at the present time, do not view it as a sign of failure. Consult with a member of staff from a support service for advice on what to do or encourage the student to make contact with an appropriate person who can formally assess and refer on e.g. Student Support Services, their GP, or the Counselling Service.

  • If you do feel able to start an initial discussion with the student yourself, you might:

    - Ask the student how they have handled similar difficulties in the past, highlighting what has and has not worked.
    - Explore with the student what changes they would like to make to enable them to continue with their studies.
    - Break tasks down into shorter term and more manageable goals.
    - Refer to your institution's directory of services/handbook if further help is needed.

    However, it can be extremely stressful and time consuming helping a student, which is why it is important to remember to look after yourself and seek appropriate support and help from others (see section 4).

  • A flow chart summarising these practical guidelines can be found in the appendix to this manual (section 7).
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3.2.5 Handling crisis situations

Most of the time the steps outlined in the guidelines in section 3.2.4 are sufficient. Occasionally, however, the student concerned may reach a point of crisis, and this section has been included to raise awareness and provoke thought about what to do in such a situation. However, it is important to emphasise two points:

  • people experiencing mental health problems are very rarely violent towards others; and

  • crisis situations are extremely rare and can be prevented. This highlights the importance of adopting a pro-active approach in the area of student mental health.
A crisis situation occurs when a student's feelings have become outside their control. These emotions might express themselves in a number of ways, for example self-harming, talking about suicide or having persistent suicidal thoughts, having no sense of reality and exhibiting behaviour which is out of character. However, many crises occur in private rather than in public.

In all crisis situations, assuring your safety and that of others, including the person involved, is paramount. These guidance notes may help you:

  • Try to remain calm and adopt a non-threatening approach (in most cases calm behaviour by others is all that is required). Do not approach the student from behind without warning, nor stare at them, as this could be interpreted as threatening.

  • If there are other students about, calmly ask them to leave the area.

  • Some situations can be very frightening and distressing. If you do not feel confident to approach the student, then go and get help.

  • If you stay with the student, give the student room to breathe, and do not touch them unless you are sure that they do not feel threatened by you.

  • Explain your actions before you act and continue to reassure the student, without being patronising, about what is happening.

  • Take threats of suicide seriously - do not ignore them - it is a myth that 'those who talk about it don't do it'

  • Ensure appropriate people are contacted. If a student becomes severely disorientated or dangerous to themselves or others it may be necessary to call a GP, the local hospital accident and emergency service, your institution's security or, if necessary, the police.
In all situations, whether they are crises or not, each case must be treated individually. A person's mental health problems may fluctuate from week to week or even from hour to hour and the level of support needed will vary from person to person.

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3.2.6 Confidentiality

  • Codes of confidentiality: there will be different levels of codes of confidentiality across the institution as certain services (e.g. GP's, counsellors, chaplains) have their own professional standards of confidentiality, in addition to overall institutional policy. With specific reference to mental health difficulties, staff not bound by such professional codes still need to respect confidentiality in order to encourage students to seek help where needed. Students need to know that any information they give will be treated with respect and that it will be passed on to only those who need to know.

  • Protocol for sharing information: information about students with mental health problems, or suspected mental health problems, should be obtained and shared only for the purposes of providing care or for the protection of the students or others on a need to know basis. Information which needs to be written should be written in a non-discriminatory manner (not using diagnostic labels) and the use of jargon should be avoided. It should highlight the support needs of the student not their clinical diagnosis, which can cause labelling and does not tell a person anything about how to support an individual.

  • Obtaining consent: the student should always be asked to give consent before information is shared. It is important that where consent is given by the student, it is informed consent. Therefore it is necessary to tell the student concerned why there is a need to disclose information, who will have access to that information and the likely consequences of giving or withholding consent e.g. explaining why academic work might be delayed. Once consent has been obtained, it is the responsibility of the person passing on the information to ensure that this is carried out only on the terms agreed with the student.

  • Information for external agencies: if information is required by outside agencies (via phone, letter etc.), for example by social workers, psychiatrists or GPs, the rights of the student should be protected. Information cannot be disclosed to any third party unless the student has given consent for information to be passed to outside agencies. It is essential to clarify why the agency requires this information before imparting it, and whether it is pertinent and relevant to that student's care and treatment, or their safety or the safety of others.

  • Requests for information from relatives: it is not uncommon for some staff to be contacted by concerned parents or relatives. While it may be useful to provide a sympathetic ear, the institution's normal position would be that personal information can not be disclosed to parents/relatives without the consent of the student.

  • Means of disclosure: disclosure of information can take place not only verbally or in writing but also as a result of papers left on a desk or through a computer screen left on in a public area. Appropriate measures to keep information secure will be a requirement of institutional policy on confidentiality and data protection.

  • Exceptions to codes of confidentiality: as a general principle, if the student refuses or does not give consent, then information cannot be shared. However, there may be exceptional circumstances where there is a need to act without a student's permission, e.g. if their mental health has deteriorated to the extent of threatening their personal safety or that of others or there is a legal requirement to disclose information (i.e. a crime has been committed).

    Also, certain courses which involve caring for the public (e.g. nursing and medicine) may have additional criteria with regard to exceptions to maintaining confidentiality, as students are technically practising professionals as well as students, and may need to conform to external criteria with regard to 'fitness to practice'. In these circumstances, very clear information must be given to students about when exceptions may have to be implemented and about the relationship between support and other services e.g. occupational health and a student health or counselling service. Reference: AUCC on Clothier report and counselling services, www.bac.co.uk/members_visitors/expert_area/expert_frameset5.htm

  • Data Protection Act: under the 1998 Data Protection Act, all data relating to a person's physical or mental health is regarded as sensitive personal data. For guidelines on the processing of sensitive personal data under the Act (with special reference to Student Support Services) see www.dpa.lancs.ac.uk/guidelines.htm

For further guidance on good practice with respect to confidentiality and disclosure of information, see: AMOSSHE 'Duty of Care' document (examples of good practice on use of personal data in appendix)

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3.3 Specific support arrangements for students with mental health difficulties

This section is concerned with support arrangements which relate to specific areas of the student experience.

3.3.1 Learning support

Learning support for students with mental health problems has been particularly well developed in the field of adult, continuing and further education. Students who come from these sectors to higher education may have experienced extremely good support in this area. Those working in higher education may find that there are methods used in these sectors which could be adapted to teaching in higher education and may prove to be good practice in general (see also section 6.6).

The issue of learning support for students with mental health difficulties is a major subject area in its own right and an extensive resource on good practice is being developed by NIACE , "Pathways for Inclusion. Widening Participation in Post-16 Education. An A-Z of educational practice for mental health" (Reference: www.niace.org.uk). The purpose of this section is simply to give a brief summary of some elements of good practice for those involved in the teaching of students with mental health difficulties in higher education:

  • Emotional support: this is often all that may be required and may involve access to an individual who might sit with the student in lectures, classes etc and generally be available particularly in the early stages. Such a supporter would not be identified as such and might be introduced as another student i.e. the support would not be overt. The supporter could be a volunteer but it is to be recommended that they are actually employed (possibly funded through the Disabled Students' Allowance) for reasons of reliability and also training requirements.

  • Identification of needs: discussion of learning support needs should not involve diagnosis or labelling. It is not necessary to do either in order to ask the student what might assist them. The educational experience may be the first opportunity a student with a history of mental health difficulties has had to put labels aside and concentrate on their academic potential.

  • Flexibility: flexibility is the key to learning support. The more flexible the teaching and assessment system is, the more possible it is for a student to achieve their potential, despite interruptions due to fluctuations in their health, periods in hospital etc.

  • Co-ordination: a named co-ordinator of support for students with mental health difficulties may be very helpful in negotiating between students and staff. This needs to be a relatively senior position to ensure credibility, especially where there is a potential challenge to established teaching methods.

  • Terminology: although an acceptable alternative to the term learning support is not readily identified, some students offered learning support in response to a declaration of mental health difficulties may feel that it insults their intelligence and capability. Higher education has a major role to play in influencing attitudes in this area. It can show that people studying at this level may benefit from learning support, which in no way reflects their intellect and academic potential. It may simply be about managing certain barriers that they encounter in the student experience.

  • Reference: 'Open University Teaching Toolkit: Supporting Students with Mental Health Difficulties', http://www.ouw.co.uk/products/OTTK014.shtm
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3.3.2 Examination and assessment

Given that periods of examination and assessment are generally the most stressful experiences for students, those with mental health difficulties may need special support at such times. Although good practice in terms of minimising stress will benefit all (see section 6.6), certain specific arrangements may need to be considered for students with mental health difficulties. These need to be discussed and agreed with the student as early as possible (see section 3.1.3). Some students will not want any special arrangements at all. Arrangements might involve:

  • Examination room: it may be appropriate for the student to sit in a smaller room rather than a large examination hall or even a room on their own, although this could be equally intimidating to some. Location within the examination room may also be important e.g. near a window or exit.

  • Technical assistance: for those who have difficulties writing under pressure the use of a computer may help. Others may be offered amanuensis, but again, this can be intimidating unless well practised first.

  • Extra time: it may assist if the student is given some extra time (e.g. to read the paper), but this can draw out the stress of the experience. Alternatively, breaks might be given within the assessment to lessen pressure and make the experience less tiring for those who may be affected by medication etc.

  • Special support: a general awareness of vulnerability around assessment periods may be needed with access to a named member of staff who can help with tactics and liaise with other staff members, especially if the student has times of hospital admission etc during critical assessment periods.

  • References:
    [1] AMOSSHE 'Duty of Care' document for example of good practice on examination arrangements, www.amosshe.org.uk/news.asp

    [2] 'Open University Teaching Toolkit: Supporting Students with Mental Health Difficulties', www.ouw.co.uk/products/OTTK014.shtm

    [3] University College of Northampton, 'Special arrangements in examinations for students experiencing mental health difficulties', www.northampton.ac.uk/stu/addlneeds/MH-015.doc

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3.3.3 Fieldwork
  • For those students who experience mental health difficulties, fieldwork and other such activities may prove particularly stressful, given the removal from normal social, professional and support networks, the change in environment, community living and the sense of exposure this may bring, as well as unpredictable physical and practical challenges. Thorough planning by fieldwork organisers is needed in areas such as content of briefing materials, training in dealing with unexpected difficulties and awareness of protocols in an emergency.

  • Reference: full guidance can be found in the document: Birnie,J. & Grant,A. (2001) 'Providing Learning Support for Students with Mental Health Difficulties Undertaking Fieldwork and Related Activities' (Cheltenham: Geography Discipline Network) from: www.chelt.ac.uk/gdn/disabil/mental/

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3.3.4 Careers advice

  • Students with mental health difficulties may have special concerns in relation to the transition from higher education to employment or training. The effects of mental health difficulties may have different implications in the working environment. Moreover, given the problems over stigma and possible discrimination in society in relation to mental health difficulties, students may need specific advice on their rights and on the question of disclosure.

  • Reference: 'Advising students and graduates with mental health difficulties' produced by members of the Disability Development Network (Essylt George, University of Wales Institute, Cardiff; Kate Croucher, Middlesex University; Caroline Harvey, Coventry University). Copies can be obtained by contacting Val Farrar, University of Central Lancashire: vfarrar@uclan.ac.uk (Tel: 01772 892584)
3.3.5 Accommodation
  • Arranging special provision: where a student declares a mental health difficulty prior to entry (see section 3.1.1) this gives the opportunity for any specific requirements in relation to accommodation to be discussed.

    - If institutionally managed accommodation is requested, the student may wish to discuss whether they wish any specific residential staff to be aware of their difficulties and any needs in relation to location of room (e.g. quiet corridor, particular floor of building) etc. Any relevant support arrangements need to be discussed and agreed with the student, with the reassurance as to how information will be used and that it will only be used in the student's interests. Accommodation staff will need to have received some basic training and will need access to expertise from support services.

    - If the student is not to live in institutionally managed accommodation, they may still need an opportunity to discuss travelling arrangements, alternatives if private accommodation becomes unsuitable etc.

  • Incidents in residence: where a student does not declare a mental health difficulty, the first occasion that a difficulty is identified often arises from an incident in institutional residence. For this reason it is particularly important that residence staff (including senior students, hall tutors, domestic staff, portering/security staff) are fully conversant with the relevant protocols (see section 3.2.5) and have undergone mental health awareness training (see section 5). An incident relating to mental health difficulties in a residential student community can have a major impact on other students as well as staff. Support services may need to be available for debriefing sessions for staff and students involved.

  • Transitional accommodation: should a student require hospital admission there may be an issue as to suitable accommodation on discharge. Returning immediately to a hall of residence, for instance, may not always be suitable if it is felt that there is not adequate support in place. Effective liaison with external services (see section 3.5) such as the CPN and community health team may enable arrangements to be made for a placement in a 'half-way house' in such cases. Such situations are much more easily managed if a student has been given the confidence to share relevant information with those involved.

  • Communal living: in the context of shared student accommodation, whether institutionally or privately managed, it is frequently other students who are most involved with a student who is experiencing mental health difficulties. Access to advice and support is crucial in such circumstances (see section 4).
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3.3.6 Financial support
  • Financial advice: institutional support services will need to be able to advise students with mental health difficulties on the procedures and types of financial support available to cover any additional costs arising from their mental health difficulties in the context of their studies. For instance, there may be equipment needs, such as an audio tape recorder for recording lectures if there are problems with concentration. IT equipment may enable distance learning if there are times spent away from the institution (at home or in hospital) during more severe episodes of ill-health or it may help where handwriting is badly affected by stress or anxiety. Detailed assessment may be referred to a professional service or centre (e.g. Access Centre).
    Reference: for detailed information see www.skill.org.uk

  • Disabled Students' Allowance (DSA): under the definition of disability for DSA, students with mental health difficulties may be eligible for help with extra costs as a result of attending a course and as a direct result of their mental health difficulties. Documentation will be required by the LEA and an independent assessment may be needed.
    Reference: SKILL: www.skill.org.uk and 'Bridging the Gap' (DfES): www.dfes.gov.uk/studentsupport/students/stu_students_with_d.shtml

  • Hardship funds/loans: institutions may allocate hardship funds, loans and any other internal welfare funds to support students who need extra help because of mental health difficulties, if they have higher than expected costs as a result. In view of the particular issues around declaration of mental health difficulties and confidentiality, the handling of such allocations may need to be done especially carefully.
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3.3.7 Student Support Services

There are a number of student support services which may or may not be grouped under a general student service department (which may also include services such as careers and accommodation) which are all likely to have direct involvement with students with mental health difficulties. Some of these services have distinct codes of conduct e.g. on confidentiality and will approach mental health issues from differing angles. However, good communication lines between services and some commonly held protocols will help to ensure consistent treatment of students with mental health difficulties and lessen misunderstandings over individual cases. As each service will have its own methods of operating and access to advice and networking for its personnel the purpose of this section is to provide a brief summary with references to the appropriate professional bodies and organisations:

  • Counselling Service: this is often the main service to which internal referral is made or which identifies students with mental health difficulties. Issues around confidentiality, liaison with external mental health services etc are all critical for counselling services and considerable expertise and experience has been accumulated:
    References: www.studentcounselling.org; www.hucs.org

  • Student Health Service: where an institution has its own health service for students this may be another front line service for supporting students with mental health difficulties. There will normally be arrangements regarding referral to external health services (e.g. local psychiatric services) and some institutional services may have direct input from a CPN or mental health professional: Reference: British Association for Health Services in Higher Education, bahshe@jiscmail.ac.uk

  • Disability Service: some students with mental health difficulties may be referred initially to disability services, for instance when a mental health difficulty is declared on a UCAS form and such declarations are monitored by disability services. The disability service may therefore take a lead in co-ordinating any support or assessment that is required: Reference: SKILL, www.skill.org.uk

  • Chaplaincy Service: where institutions have a chaplaincy or similar service, some students may choose to use this service as a first point of contact in relation to mental health difficulties. Chaplains will have specific codes of confidentiality etc around such work (see also section 3.2.6):

  • Specialist Mental Health Service: a number of institutions have recently developed specialist posts of mental health co-ordinators/advisers with a professional background in the field of mental health. As well as enabling more students with mental health difficulties to access appropriate support from within the institution, such professionally trained personnel may be in a position to facilitate particularly effective links with Local Healthcare Trusts and other external support services (see section 3.5.1).

    Reference: for overall good practice guidelines, protocol etc for the management of Student Services departments (which include some or all of the above services) with respect to supporting students with mental health difficulties, see the AMOSSHE 'Duty of Care' document, www.amosshe.org.uk/news.asp

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3.4 Role of Students' Unions

Students' Unions, representing the student body, play an important role in the area of student mental health, including:

  • Alternative support service: students may choose to access a student run support service concerning their mental health difficulties. Institutions need to recognise that this may happen and that such diversity of support can be beneficial. Institutional and student run services will benefit from good dialogue to ensure there are no misunderstandings over protocol and that the students seeking support are encouraged to access the full range of services they may require. It may be appropriate to include representation from student run support services in case conferences where continuity is important (e.g. where a student has first presented at a student run welfare service and consequently is involved with institutional or external services).

  • Policy development: it is critical that there is Students' Union representation from the first stages of any development of policy and protocol by the institution in the area of student mental health (see section 2).

  • Training: Students' Union welfare services have access to training in the area of supporting students with mental health difficulties, which may include advocacy training. They may also have a role in training other students in mental health awareness. Those running institutional training may therefore wish to work co-operatively with Students' Union initiatives in this area. This is particularly appropriate where student volunteers are providing an important initial support and referral service.

  • Lobbying: Students' Unions have a key role in lobbying activities in terms of tackling discrimination and many of the factors which may affect mental well-being in general (section 6). Institutions may find that encouraging and promoting Students' Unions' mental health awareness campaigns is an effective way forward with limited resource implications.
    Reference: this section has been compiled in consultation with NUS (National Union of Students) who lead national policy, training and initiatives in the field of student mental health. For more information on the role of NUS see www.nus.org.uk
3.5 Liaison with external agencies

Excellent links with external agencies are critical in providing optimum support for students with mental health difficulties. External agencies include local health services (mental health care teams, psychiatric services, Local Healthcare Trusts, GP's etc) as well as local and national voluntary organisations and local user groups.

3.5.1 Local health services

  • Established support: some students who experience mental health difficulties may come to the institution with links with mental health services already in place. If this is declared, it may be possible to discuss with the student whether these links are in their view sufficient or whether they wish to have any additional support from within the institution. The student may wish to give their external support service (e.g. Community Psychiatric Nurse) some information from the institution about its structure, nature of course, support services etc in order for them to discuss strategies for student life. Where a student's external support has come from a different region, there may be issues around ensuring continuity with provision in the institution's locality, including effective referral in vacation periods.

  • Cross referral: effective cross referral between internal support services (e.g. counselling service) and external services (e.g. community health team) are very important. For the system to work in the student's best interests both services need to understand each other's methodologies and codes of practice. Agreement and understanding will also be needed on confidentiality protocol, especially where a student is admitted for in-patient treatment and then discharged back to the institution. The whole process will operate most effectively if named contacts are identified in external and internal services and these individuals communicate regularly, possibly attending appropriate meetings in each other's services, so a full understanding of operational methods and approach is gained.

  • Case conference: case conferences which are held on individual students where there is, for instance, a disciplinary issue (see section 2.5.5) may benefit from participation of an appropriate external professional e.g. GP, CPN.

  • Discharge from in-patient treatment: when a student is discharged from hospital back to the institution, particularly where institutional accommodation is involved, support problems may arise. This transition may be eased by close liaison with local mental health services on, for instance, the use of a 'half-way house'.

  • Rationalising workload: institutional support services (e.g. counselling services) may be able to offer support and sessions on issues (e.g. eating distress) which occur particularly commonly in the student community, thus enabling local community health teams to concentrate on acute areas of student case work. Given long waiting lists in some areas and pressure of work it is helpful for there to be opportunities to rationalise workload in such ways so that where urgent referral to external services is required this can be done most efficiently.

  • Role of mental health co-ordinator: institutions which have a professionally trained mental health co-ordinator (see section 3.3.7) may be able to make especially effective links with their Local Healthcare Trust, on the basis that the Trust would accept direct referral from a mental health professional. Such a specialist may also have particular credibility when interpreting the unique aspects of student life to external healthcare services (e.g. the problems of short academic timescales if there are long waits for an assessment or the difference between discharge to a home environment and to unsupported student accommodation).

  • References:
    [1] HUCS/AUCC on professional links (including recommendations in HUCS report, 1999, 'Degrees of Disturbance'), www.studentcounselling.org; www.hucs.org

    [2] UUK document (appendix - examples of good practice), www.universitiesuk.ac.uk/bookshop

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3.5.2 Voluntary organisations

  • There are voluntary organisations, user groups and non-statutory agencies which represent and support people with mental health difficulties. Many of these have a number of functions, including campaigning, education and practical advice, support and advocacy services. Some have specific sections dedicated to young people (e.g. National Schizophrenia Felowship, see section 7), which may be appropriate to certain sectors of the student population. Those organisations which have local branches should be available to students as members of the local community. Fostering good contacts with these external sources of support can greatly enhance the service institutions can offer students with mental health difficulties through appropriate referral, support groups etc as well as in training and awareness raising (see section 5).

  • References: for a list of contacts for major voluntary agencies, support groups etc see section 7.
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3.6 Appendix: Guidelines for specialist support staff on using a 'framework of questions'

3.6.1 Using a 'framework of questions'

  • The guidelines in section 3.2 are relevant, in terms of good practice, for any member of staff who encounters a student who may be experiencing mental health difficulties. Having followed the suggested procedures, it is often appropriate that an initial referral is made to a member of staff or service with a specific remit in terms of student support. A more detailed discussion of needs may be appropriate on this referral and in this context a 'framework of questions' may be helpful. This is basically an initial, first level tool, with the prime purpose of determining appropriate referral to a professional service. An example of such a framework follows, with the emphasis that this is just one example of a tool that can be fully or partially used.

  • Any such detailed discussion, whether or not using the framework, should only be undertaken by staff with the relevant experience and responsibility in the field of student support. It is essential that those who use such a tool have the expertise and remit to identify further action or correct referral. They must be able to give access to full information on all alternative routes of advice and support both inside and outside the institution.

  • It is critical that staff do not attempt to work outside their limits of competence. The framework of questions cannot replace any professional assessment and is not intended to encourage staff to try to substitute for mental health professionals or to engage in amateur diagnosis.

  • Some people may choose to use the framework openly, filling it in with the student, if agreed. Others will familiarise themselves with its content before a meeting so that they are confident in the areas they will cover, but are not distracted by paperwork at the time of meeting. If it is used as a form to be completed in the presence of the student, the student must be happy with everything that is written and be offered a copy of the form afterwards. It must always be remembered that anything written or recounted about an individual should be done with their full permission and for their benefit. See section 3.2.6 for guidance on confidentiality and the use of personal data.
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3.6.2 An example of a 'framework of questions'

Guidance for Staff
This questionnaire can be helpful when talking to:

* Students who have identified they have mental health problems.
* Students who have been referred to you by other staff or other students.
* Students whom you are concerned about with respect to their mental health
This framework of questions is not intended to be prescriptive; it aims to provide staff with a set of prompts enabling them to ascertain the needs of individual students. The interview should be conducted in a non-judgmental way with information given and not advice. Each interview conducted must be tailored to the individual student.
These questions can be adapted to suit your style and needs and do not have to be asked in this order, nor do all the questions need to be asked.
You may feel this questionnaire is appropriate for students to complete themselves.

Introduction:
The introduction is one of the most important elements of an interview. The aim is to put the student at ease, which will hopefully promote a more interactive interview.

*Choose a quiet and comfortable place to conduct the interview.

* Divert all you telephone calls, if possible.

* Try to ensure the seats are arranged in a non-intimidating way (preferably on an equal level)

* Ask general questions to start off with: easy, straightforward questions such as how are you, did you have any difficulties getting here, introductions etc.

* Explain to the student that the questionnaire aims to highlight how/if the university can help them.

* Wherever possible, ask an open question (i.e. a question, which can not be answered by one word)

* However, to begin with, it may be a good idea to ask some closed questions which do not put the student under too much pressure.

* Ask the student if you can make notes throughout the meeting.

* Make it clear to the student that they do not need to answer any of the questions if they do not want to.

* Reassure the student that everything that is said or written is confidential and will not be shared with anyone else without their consent.

[1] What was it like for you coming to university (e.g. how did you feel before you came, is it what you expected, how is it different?)

[2] Are there parts of university life you find very stressful?

Supports, Stability and Responsibilities Section:
This section aims to help you identify with the student where their areas of stress are.

[1] Have you any worries/concerns/problems in the following areas of your life, presently?

Accommodation
Finances
Physical health
Family
Friends
Partner
Social life (e.g. alcohol/drug consumption, lack of friends, isolated)
Studies (e.g. lectures, workload, lecturers)
Discrimination (e.g. bullying, harassment, racism)
Emotional/mental health (e.g. mood swings, depressed, panic attacks, anxious, problems with sleeping)

[2] If yes, are these worries interfering with your studies or daily living?

[3] Would you like some help to change things and if so what sort of help?

More support from family
More support from friends
More support from academic department, college etc
Advice and information on managing money
Advice and information on managing studies e.g. time management, writing assignments, sitting exams
Medical advice e.g. GP, practice nurse, family planning, helplines.
Specialist support , e.g. counselling, helpline, self-help group

If the student identifies they would like further support, refer to your institution's directory of services/handbook for the appropriate service, person, helpline etc.

The following section aims to gain an understanding of the effects of medication, if a student is taking some, which may influence an academic department, college etc to make adjustments which are helpful for the student.

[1] Do you take any medication?

[2] If yes, do you understand why the medication has been prescribed and what the benefits and limitations are?

[3] Do you experience any problems with the medication which interferes with your university life?

[4] Are you aware of other activities which may help, as well as the medication -

Complementary therapies, e.g. massage, reflexology, relaxation, meditation;
Support groups/self-help groups;
Exercise

If the student expresses an interest in one of the above areas, refer to your institution's directory of services/handbook for the appropriate service.

General Questions:
[1] Do you think that there might be any particular situations that you might find difficult to cope with while studying here?

[2] What tends to have triggered off your distress in the past? What sort of strategies have been useful in the past? (There may be similar resources available on or off campus - refer to your institution's directory of services/handbook)

[3] If you felt you were building up to a crisis situation, whom would you like to be contacted? (A lot of thought must be given before this sensitive question is asked - is it appropriate or relevant to ask?)

[4] If you had a problem while at university, how would you sort it out? Are you aware of the range of support services on offer?

[5] Have you found any of the services unhelpful? Have you found any particular service, person, group helpful?

[6] Do you feel the university's departmental procedures, policies, environment, housing and support systems etc., support your needs? If no, why not?

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