Keywords

1 Introduction

The third sector refers to those organisations and groups which make a non-governmental and not-for-profit contribution to civic society. It is also known as the voluntary or community sector or the civic or societal sector [1]. It includes charities and co-operatives, social enterprises and self-help groups. The third sector has an expanding role in those western societies, including England, whose governments are seeking to reduce direct statutory involvement in the running of public services [2].

One way of understanding the role of the third sector is to consider it as positioned in the middle of a continuum or pyramid of care, stretching from self-help at one end to specialist care at the other (see Fig. 11.1).

Fig. 11.1
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Third sector and pyramid of care

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Third-sector organisations such as charities, self-help groups and faith communities can play a substantial role in addressing those mental health problems, such as anxiety and depression, which are commonly experienced by older people. However many primary care professionals, including general practitioners, are unaware that such potentially rich resources and support may be available nearby. This chapter is designed to give primary care professionals some new perspectives and ideas on how the third sector can provide much needed help and support in the identification and management of common mental health problems in older people.

In this chapter, we describe four ways in which the third sector may be involved in helping to reduce symptoms of depression and anxiety amongst older people. These are befriending, increasing physical activity, guided self-help and collaboration between community groups and health-care providers. The first three are examples of how the third sector can deliver services to the benefit of older primary care patients with mental health problems. The fourth offers insights into how community groups and primary care teams can work together to improve services for older patients.

This is by no means an exhaustive list: there are many other examples we could have chosen, for example, debt or bereavement counselling, arts-based activities such as reading or singing groups and the act of volunteering itself. We have focused on these four because they are examples of third-sector activities that are supported by evidence of benefit for older people with symptoms of anxiety and depression.

We then provide a case study of one successful third-sector intervention, a guided self-help initiative for older people, and include the perspective of a service user.

Finally we offer readers the opportunity to reflect on their own practice.

2 Befriending

Befriending is an emotional support intervention commonly offered by the voluntary sector. It is usefully defined as ‘a relationship between two or more individuals which is initiated, supported and monitored by an agency that has defined one or more parties as likely to benefit. Ideally the relationship is non-judgemental, mutual, and purposeful, and there is a commitment over time’ [3]. In the UK, for example, more than 500 charitable and voluntary sector organisations currently offer befriending services [3].

Befriending can be helpful in reducing depressive symptoms and emotional distress amongst older people, particularly those who are isolated and lonely.

Mead and colleagues conducted a systematic review of randomised trials of interventions focused on providing emotional support to individuals in the community. Their aim was to examine the clinical and cost-effectiveness of befriending for individuals in the community, with a focus on the impact on depressive symptoms and emotional distress. They found 24 suitable trials, of which five were focused on older people. Compared with usual care or no treatment, they found that befriending has a modest but significant effect on depressive symptoms and emotional distress, both in the short term and the long term [4].

A good example of a befriending service is Reclaiming Joy, a mental health peer support programme for low-income older adults in Kansas, USA. In this programme, an older adult volunteer is paired with another older adult with mental health problems who is in need of peer support. Volunteers receive training on the strengths-based approach, mental health and ageing, goal setting and attainment, community resources and safety. The pairs meet once a week for 10 weeks. Participants establish and work towards goals that they feel will improve their mental health and wellbeing. In a pilot study of this service, 32 participants completing the intervention were assessed. There was statistically significant improvement for symptoms of depression, although not for symptoms of anxiety. Quality-of-life indicators for health and functioning improved for participants with symptoms of both depression and anxiety [5].

Telephone friendship support has been suggested as an alternative and perhaps more cost-effective method of providing befriending services. A study in Sheffield, UK, tested a service for people aged 75 and older where 6 weeks of short one-to-one telephone calls were followed by 12 weeks of group telephone calls with up to six participants, led by a trained volunteer facilitator. Although it was feasible to find suitable study participants, it proved more challenging to identify sufficient volunteer facilitators to run the service. The study leaders suggest that, to be a success, a programme like this would need to recruit volunteers from more than one city and might also need dedicated management of the volunteers [6].

3 Increasing Physical Activity

Physical exercise, especially when linked to social and communal activities, is beneficial for the mental health of older people. Third-sector organisations can be effective in providing opportunities for older people to experience these benefits.

This is the case when physical exercise is considered generally. Older people living in two low-income housing estates in San Francisco were encouraged to increase their physical activity by taking part in existing community-based physical activity classes and programmes of their choice. Participants were encouraged to adopt activities tailored to their preferences, physical abilities, health status, income and resources for transport. Those who adopted and maintained a new physical activity over 6 months experienced greater improvements in anxiety, depression and overall psychological wellbeing relative than those who did not [7].

It is also the case for physical activity tailored specifically to the needs and interests of older people. We note here the evidence for the beneficial effects of two types of activity supported by third-sector organisations: gardening or green gyms and the ‘Men’s Sheds’ movement.

The cultivation of a garden plot can contribute to good mental health. In a seminal qualitative study on this subject, Milligan and colleagues note the importance of the wider landscape and the domestic garden in the lives of older people and illustrate the sense of achievement, satisfaction and aesthetic pleasure that older people can gain from their gardening activity. They propose that communal gardening on allotment sites ‘creates inclusionary spaces in which older people benefit from gardening activity in a mutually supportive environment that combats social isolation and contributes to the development of their social networks’ [8]. Evidence is accumulating in support of these propositions, including statistically significant improvement in measures of mental health and self-esteem [9]. The awareness of being away from one’s usual setting and fascination with the processes and achievements of gardening are important components of its therapeutic effects on older people with depression [10].

The Men’s Sheds movement is a rapidly developing intervention for older men, which has spread from Australia to several parts of the Anglophone world including the UK and Ireland [11]. Men’s Sheds provide a communal space for older men to voluntarily engage in practical activities, particularly woodwork. It is estimated that across Australia there are more than 550 Men’s Sheds with approximately 50,000 older men, attending on a regular basis. There is expanding evidence to indicate positive effects of Men’s Sheds on the mental health of older men [12]. The consistency and frequency of such reports suggests that older men find benefits to their mental health from participating in social and physical activities in Sheds, due primarily to a greater sense of belonging and purpose in their lives:

Men experience a range of very positive benefits as a result of participating. They feel better about themselves, are happier at home, have a strong sense of belonging and enjoyment and greatly appreciate the opportunity to be accepted by, and give back to, the community through what they make and do. [13]

4 Guided Self-Help

Third-sector organisations have an important role to play in the provision of low-intensity psychological interventions, which are of particular benefit to people with mild to moderate symptoms of anxiety and depression [14]. The role of third-sector organisations is expanding in countries such as England, where there is currently a policy imperative to allow any qualified provider to tender for previously statutory services [2]. It is also valuable in situations where long waiting lists cause delays for face-to-face treatment and for those people who prefer not to seek health service help. This is of particular importance to older people, who may be less likely to see primary care as an appropriate place to present or discuss mental health problems [15].

Cognitive behavioural therapy (CBT) can be effectively implemented by third-sector self-help clinics. Beating the Blues is a computerised CBT package which has been shown to reduce symptoms of depression and anxiety. In England, a third-sector organisation led by service users set up a self-help clinic to guide people through this package. They received over 500 referrals during their initial evaluation period. They found good evidence of recovery in half of those who met case criteria for anxiety or depression and had completed at least two sessions of CCBT [16].

In Scotland the charity Action on Depression is offering a life skills community course to people with symptoms of low mood. This is an eight-session community-based cognitive behaviour therapy group intervention called Living Life to the Full. It can also be taken up online if people prefer. Participants are recruited from the community through newspaper adverts and via the charity’s website. This intervention is currently being evaluated by a randomised controlled trial [17].

The Netherton Feelgood Factory is a community-led healthy living centre based in Merseyside, England. Amongst its activities, it offers the Positive Thoughts Course, a group psycho-education programme which combines CBT and social network approaches. This programme is based on the Coping with Depression course, which has been shown to be effective in reducing symptoms of depression in community settings [18, 19]. One of the Positive Thoughts Courses is designed specifically for older people. We described this course in more detail later in this chapter, in our case study.

5 Collaboration Between Community Groups and Health-Care Providers

The previous examples have all been of services provided by third-sector organisations, which are likely to be of benefit to older primary care patients with mental health problems. In this section, we describe innovative ventures in which primary care or mental health-care teams have worked together with voluntary community organisations to achieve more accessible and acceptable services for older people.

5.1 The Amalthea Project

It is well recognised that, due in part to time constraints and lack of local knowledge, general practitioners and other primary care health professionals are often unable to refer patients with mental health problems to voluntary services that might be able to help them. In Bristol, England, the Amalthea Project was commissioned by general practitioners who wanted improved access to the numerous voluntary organisations with a potentially useful role in the management of psychosocial problems. This NHS-funded project was set up to collect information about the voluntary sector. Referral facilitators were employed to assess patients and recommend appropriate voluntary organisations. The project aimed to improve patients’ quality of life and to decrease time spent by health-care professionals dealing with psychosocial problems. In a randomised controlled trial, patients referred to the Amalthea Project made greater use of more than 25 voluntary sector services (including local social groups for the elderly, bereavement charities, the University of the Third Age and the Royal British Legion) than those who received usual care. They showed significantly greater improvements in anxiety, other emotional feelings and quality of life, although no differences were detected in depression or perceived social support [20].

5.2 Beat the Blues

It is important to ensure that services meet the needs of the people they are supposed to help. Community organisations can provide crucial intelligence in ensuring that this actually happens. Older African Americans, for example, are at high risk for depression due to high levels of chronic illness, disability and socioeconomic distress. However they often do not access existing primary care or mental health services because they do not see them as likely to meet their needs. In Baltimore, USA, a collaboration between a senior centre and a local mental health resource has resulted in the creation of a new programme called Beat the Blues (different from the Beating the Blues CCBT package we noted in the previous section), designed specifically to meet the mental health needs of older African Americans. Licensed senior centre social workers trained in Beat the Blues meet with participants at home for up to ten sessions over 4 months. They assess care needs and make referrals and linkages with other community resources. They also provide depression education, instruct in stress reduction techniques and use behavioural activation to identify goals and steps to achieve them. They are currently conducting a trial to test whether Beat the Blues reduces depressive symptoms and improve quality of life in more than 200 African Americans aged 55 and over [21].

5.3 The AMP Programme

A potentially powerful example of involving third-sector organisations in the planning and delivery of high-quality services for older people with common mental health problems is the AMP Programme from north-west England [22].

The AMP Programme created a multilevel intervention model designed to increase equity of access to high-quality mental health services in primary care. The model involved intervening simultaneously at three levels: community engagement, primary care training and tailored psychosocial interventions (see Fig. 11.2).

Fig. 11.2
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The AMP intervention model

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This model is based on the assumption that intervening at three levels would be mutually reinforcing and thus more effective than intervening at one or two levels. We describe here how the model was deployed to meet the mental health needs of older people living in an area of high social deprivation.

The community engagement element involved gathering information about existing local resources, identifying a community champion and setting up a consultative group to identify key issues and set an agenda for action. The consultative group was based in a resource centre for older people and brought together, for the first time, representatives of local third-sector organisations (including faith groups, education providers and older people’s advocacy groups) and primary care teams and also representatives of the police, housing associations, employment, health commissioners and local politicians. Its main activities were disseminating information about locally availably services for older people and strategic involvement with citywide mental health policy. These activities provided opportunities to increase cooperation between third-sector organisations, develop links between these organisations and primary care and raise the profile of the mental health needs of older people across the city.

The primary care element consisted of an interactive training package: a training component, advice on practice organisational features that may impede or promote access by underserved groups and raising awareness of relevant third-sector organisations and resources. It was particularly effective in practices where a senior member of the team acted as an advocate or champion of the interactive training package.

The psychosocial or ‘wellbeing’ interventions were based on cognitive-behavioural principles, with an emphasis on social participation. They were modified to suit the needs of older people following consultation with local focus groups. There were positive effects on depression and wellbeing for those older people who received the interventions, compared with those who received usual care [23].

A health commissioner was enthusiastic about the benefits of the integrated AMP model:

I think about the whole thing . . . so the AMP is improving access to mental health and primary care and then you have got the well-being facilitators and – really exciting and well done – for the bit that says in our, you know, here are the facilities, here are the local things that we have in our local community, which for us in a practical world is really helpful. Really helpful for GPs, really good to say, listen here’s – you know – here’s what you’ve got.

Community engagement led to an increase in referrals to the AMP psychosocial interventions. The quality of mental health care for older people within primary care was enhanced by the information-gathering element of the community engagement strategy, enabling more active linkage with community-based resources, and by the offer of access to the AMP psychosocial interventions [22].

6 Case Study

The Elderly Positive Thoughts Course is a group psycho-education programme, specifically designed for older people, which combines CBT and social network approaches.

The course takes a cognitive-behavioural approach, based on the assumption that how we think and feel affects what we do [24]. But what we have forgotten, or maybe never even worked out, is how we really feel. How many times when we are asked “How are you?” Do we say, “Fine thanks”, without even thinking for a moment how we actually feel? Or do we say, “Oh, I’ve been so busy”, which completely bypasses the question of feeling? Each week, every participant gets the opportunity to say how they feel in a safe, accepting environment. We do not “fix” feelings, but acknowledge their validity and explain the importance and value they have in our lives. It is important that each participant understands from the start that this is not a therapy where they just talk but that they will be required to learn and practise new techniques that will make them feel more positive about their lives. In practice we have found this is a plus for most people who can see no value in “just talking about my problems over and over again”.

The basic structure and content of each session is a combination of feedback, discussion, relaxation and homework. It is acceptable that the style and manner of presentation may vary. Every week there is homework and one component is always a mood chart, a daily record of how we feel on a score of 1–10. This keeps the theme of feelings high on the agenda. Each session lasts approximately 2 h. This includes a tea break which further encourages social support amongst the group. The lecture notes for the instructor are intended to be the basis of the group discussion with the more detailed information being given to the participants in the form of a handout. This means that during the group there is little reading to be done. This bypasses problems with sight and reading skills.

The course covers different themes, for example, how our activities affect our mood, finding out the things we can do to make ourselves feel better and some ways to help us change our thoughts. Themes are developed in the course, both from the taught material and also from the contributions of course members. People are encouraged to bring in material and ideas that have helped them. These are discussed in the course and then there is appropriate homework. The discussions and the social support these generate are important in helping people find their own solutions.

During the course, we hope that participants will come to realise a number of things. Firstly, many other people have similar problems. They will realise that there are a number of ways of dealing with any given set of circumstances. They are likely to have both given and taken advice over the time of the course. Practical suggestions will have been made to everyone on how they can lift their mood. Everyone’s feelings will have been acknowledged, accepted and thus validated. A lot of this information would have come from within the group.

The course provides many alternative ways of looking at our lives. Some problems do not have easy solutions. Instead we need to learn to live with them or, better still, bypass them. There are sessions on good eating habits, rewarding yourself, letting others help you and having fun.

If participants can take even one change on board, they feel more in charge of their own lives. This heralds the belief that the future can improve and that they are people with the skills to improve it.

6.1 Service User Perspectives

We recently asked participants ‘What do you find helpful about coming to the Positive Thoughts Course?’

They describe the course as an important source of social support: “We have a good laugh.... Tea and biscuits and a natter”. It is also part of their routine: “It’s regular, it happens every month”. The anticipation of its occurrence is something good, a positive fixed point in an often difficult life.

It provides a safe and open space for reflection: “I can have a good moan in a neutral atmosphere – with people who usually take my side!” “There’s space for everyone to speak.... You can talk about anything”. People’s views are taken seriously: “We aren’t spoke to like we were kids”. And there is opportunity speak differently: “Sometimes I can say things I can’t say at home”.

It leads to new ways of thinking and dealing with life: “You get lots of advice from others”. “It helps you think and find other solutions”. “The course makes me feel better”.

7 Conclusions

The third sector is an important source of support for GPs and their older patients who are experiencing common mental health problems. However its potential contribution all too often goes unrecognised and underutilised.

We have provided evidence of four ways in which third-sector, voluntary, community organisations can provide tangible benefits in this field. We see these simply as examples, and there are many others that could have been presented.

GPs and other primary care health professionals are hard-pressed to deliver the quality of care to which we aspire and which we consider our patients need and deserve. It is timely – perhaps even essential – for us to have the courage and imagination to expand beyond our habitual range of contacts. We need to identify and make productive links with those many third-sector organisations that are undoubtedly flourishing within easy reach of our surgeries and clinics.

8 Opportunity for Reflection

Here are three questions to help you to think about your engagement with local third-sector, voluntary, community groups and organisations

  • What third-sector resources are you aware of locally, which could help you with the common mental health problems experienced by your older patients?

  • How many of these resources have you visited or invited to meet you?

  • How can you find out about other relevant local third-sector resources?