Guidelines for members of the Armed Forces Community. These guidelines aim to help you make informed decisions about any mental health care you decide to access.
These guidelines are fully supported by the major providers and influencers of Veterans’ mental healthcare, such as the NHS, Combat Stress, Help for Heroes, Walking with the Wounded and Big White Wall. Cobseo and the Ministry of Defence also support these guidelines.
When making a choice about any healthcare treatment you may wish to access there are two main points to consider. Firstly, it is important to ask if the treatment will lead to an improvement in health. Secondly, it is as important to confirm the treatment is delivered in a safe and ethical way.
Ideally any treatment you receive should involve tried and tested methods, and be approved by the National Institute for Health and Care Excellence (just look for ‘NICE approved’ when browsing websites). To be NICE approved, a treatment will have been tested thoroughly and there will be evidence that the treatment works. In most cases you should be offered NICE approved treatments first unless there are very strong reasons not to do so. Ideally it is advisable to discuss your treatment needs with a suitably experienced clinician before starting any treatment, NICE approved or otherwise.
However, there may be occasions when you wish to approach organisations which do not provide NICE approved treatment. A treatment may not be NICE approved if it is new or because it has not been properly tested. If you decide to accept treatment from an organisation which does not use NICE approved methods, you should always ensure that they provide you with care that is both safe and ethical.
These guidelines provide you with information about the sorts of questions you should ask so you can be confident that an organisation has taken reasonable steps to provide care in a safe and ethical way, which causes you no harm. Taking the decision to access mental health support can be daunting. The following nine principles have been created to help you ask the right questions at the right time. They also set out what should and shouldn’t happen in the early stages of seeking support.
As a general rule it is worth remembering that ‘if they do all nine, they’re likely to be fine’. This means that if the treatment provider can give you positive answers to all nine principles they are likely to be a safe and ethical service. You should also be content that you understand the pros and cons of the care being offered, including how well tested the treatment has been.
1. Principle: You should ask any mental health provider about how they communicate with your GP
Your GP should always be at the centre, overseeing your healthcare. This means they can see exactly how all care (both physical and psychological) you receive fits together.
A mental health provider should be speaking with your GP at the start, middle and end of your treatment. And should, as a minimum, let your GP know what sort of treatment they are intending to provide you with and why.
Not all treatment is accessed via your GP – it is perfectly acceptable to self-refer. In this case your GP will be informed of any agreed care plan.
Sometimes you may not want your GP to be informed of the care you are receiving. Your mental health provider will discuss these situations with you to make sure you fully understand the pros and cons of your decision.
Don’t worry if you don’t have a GP as your mental health provider will help you to find one at the start of your treatment.
If a mental health provider does not set out to communicate effectively with your GP then you should be cautious.
2. Principle: You should ask any mental health provider how they carry out an initial assessment, and if it covers substance misuse (alcohol and drugs)
Your treatment should not commence until there has been an initial assessment carried out by a qualified professional.
This assessment may include speaking with your GP, other healthcare professionals and your family. Don’t worry; this is only so a treatment plan can be developed to help you work towards having a better quality of life.
It is usual that the initial assessment should ask some questions about substance misuse and potential risk to yourself or others.
If you are recommended a treatment without a good assessment you should be cautious.
3. Principle: You should ask your mental health provider if they are NICE approved
Once your assessment has taken place your service provider will put together a care plan for you. Any treatment you receive should ideally involve tried and tested methods which are approved by the National Institute for Health and Care Excellence (NICE).
Alternative therapies or trial treatments may be suggested, but it is usual to only use these sorts of treatments alongside NICE approved ones or if NICE approved treatments have already been tried and not worked for you.
You should also be aware that if a healthcare provider discovers that you are in crisis when you access support, then reducing the risk of harm to yourself and others should become the immediate priority. Once you are out of crisis an appropriate care plan will be developed with you.
If a mental health provider does not recommend that you access an evidence based treatment first then you should be cautious. They should also tell you about their response to dealing with crisis situations you might experience.
4. Principle: You should ask the mental health provider if their suggested treatment is routine, experimental or untested
Once your treatment needs have been properly assessed the mental health provider should be honest and open with you about the sorts of treatment they can provide.
Possible treatments provided can be described as being in one of the following categories:
Routine interventions. These are NICE approved and evidence based treatments.
Experimental interventions. These are approaches that being tested as part of a well-constructed and ethically approved trial.
Untested interventions. These are treatments that currently have no strong evidence about how well they work but which the mental health provider thinks are effective. If these interventions are used, a plan should be in place for gathering evidence to allow them to understand if their intervention(s) work.
Mental health providers should be transparent in using the terms routine, experimental and untested (or equivalent) with you and your family.
You should be encouraged to discuss your treatment options with the people you trust to help you make the right decision. If it is possible, you should be given written information to take away with you which will help you, and those you trust, to make informed decisions about your care. It should be common practice for healthcare providers to suggest you try routine interventions first unless you do not want to do so.
If providers are not transparent and honest about the category of treatment they can provide you should be cautious. Sometimes disreputable providers try to describe untested or experimental interventions as being routine when they are not.
5. Principle: You should always ask which professional body your intended therapist is registered with, how they are supervised and how they’ve been trained
Your therapist or clinician should have an in-date professional registration (many are searchable online) and should always follow the codes of practice set by their professional body.
They should be appropriately supported by their supervisor to ensure you receive the best care possible. This is also why they should keep detailed, up to date notes, which are stored confidentially, on how you are responding to treatment.
These notes will be shared with your GP, as explained in principle one above. You should also ensure that the mental health provider has a system in place to give you access to your records, should you wish to see them.
Your care provider should be trained (and receive regular top up training) to ensure the safety of both yourself, and those you love, at all times.
They should discuss any concerns with their supervisors so that support, advice, and necessary action can be deployed quickly, if it is needed.
If therapists do not appear to be appropriately trained and supervised, or you’re concerned about how they handle confidential data you should be cautious.
6. Principle: You should ask the mental health provider if they have written confidentiality and risk management policies in place
Any mental health provider should employ staff that demonstrate an understanding of appropriate boundaries and who know how to deal with confidentiality in a responsible way.
Your safety, and that of others, is always the primary concern. This is why mental health providers should have procedures in place to constantly manage risk and legal responsibilities.
These procedures include acting upon, and communicating, any concerns such as child protection, to appropriate third-parties, quickly and confidentially.
All procedures should be available in a written document that you can ask to see.
Remember it is not just your therapist who will handle your information. Receptionists, assistants and other administrators may do so too. This is why all staff should have appropriate training and follow the same confidentiality procedures as the therapists.
If a mental health provider simply says that all their staff act professionally without a written policy, you should be cautious.
7. Principle: You should ask the mental health provider what their complaint and comment policy is, and whether they have a quality improvement process in place
You should always be able to provide negative or positive feedback on your care. This sort of feedback allows mental health providers to continually learn and adapt, ultimately enhancing the care they are able to offer.
It is important that the mental health provider collects data to allow them to see how effective their treatments are in comparison to other treatment providers and to continually improve their services. Without routinely collecting some data, it is not usually possible to improve the quality of services.
If services do not have a complaints/comments policy or a quality improvement process in place, you should be cautious.
8. Principle: You should ask the mental health provider if treatment is provided ‘without any strings’ attached
At times, it may be appropriate to ask if you are willing to help with media stories or fundraising by those who provide your care. However, you are never under any obligation and should never feel pressured to do so. Remember, it is always okay to say no.
If you would like to take part in these activities then your care provider / therapist should help you make a decision that puts your needs first.
Once you’ve decided to go ahead with media or fundraising, you should always be provided with the appropriate support and guidance to help you do this safely and without causing you any substantial distress.
If you feel in any way pressured to undertake any promotional activity ‘in exchange for’ treatment you should be cautious.
9. Principle: You should ask the mental health provider how they communicate with other professional bodies
Your care provider, and their staff, should always be open, honest and transparent when offering you either treatment recommendations or communicating with other care providers.
They should never try to positively or negatively influence your choice in order to meet their needs rather than yours. They should only voice an opinion if there is clear evidence that a treatment choice could be of risk to you, or those close to you.
If a clinician considers that another mental health provider has been acting unsafely they should report their concerns to a professional body.
If you are concerned about how a mental health provider is acting, you should always feel able to go back to your referring clinician who should help you report the problem in an appropriate way.
Mental health providers should also respond quickly and professionally to requests from other organisations (this could be anyone involved in providing you with healthcare). They should always consider confidentiality and their legal requirements to communicate with other professionals.
If a mental health provider does not tell you about how they will communicate effectively and appropriately with other professionals you should be cautious.
10. Final Thoughts
By always considering the ‘nine is fine’ principles you can be confident in the questions you ask any mental health provider. The responses they provide will help build a basis of trust between you as you go forward.
Whilst you may not wish to ask hundreds of questions when initially engaging with a mental health provider it is important to make sure you are sufficiently well informed to properly understand the treatment options available to you. This is so you can make an informed choice rather than simply being told what to do.
Finally, it is good to remember that the organisations that have signed up to these principles should always be able to answer the ‘nine is fine’ principles when asked. Your best interests and your welfare, and that of those close to you, should be at the very heart of all care they provide.
Strong evidence refers to material that is published in decent (high quality) scientific journals. All scientifically validated treatments (including psychotherapies) should have been tested properly in well controlled trials. A simple ‘audit’ or ‘service-evaluation’ which appears to show that people who are provided with the therapy get better is not good evidence. You should ask to see copies of the scientific papers which relate to the treatments being offered. Well accepted scientifically valid treatments will be including in NICE guidelines.
 For example the BABCP (British Association of Behavioural and Cognitive Psychotherapists), the BACP (British Association of Counselling and Psychotherapy) or the EMDR association. There are many others.